Five Counties Nursing Home: RN Staffing Failures - SD
The gap between what administrators thought was happening and what the timecards showed sits at the center of a March 2025 inspection that found the 405 6th Avenue West facility had failed to maintain required registered nurse coverage on multiple days and lacked a full-time director of nursing across 16 randomly selected weeks.
Inspectors reviewed DON B's timecards for weeks scattered between July and December 2024. The average came out to 23.125 hours per week.
When administrator A was interviewed on the morning of March 12, she said she thought the DON worked between 36 and 40 hours. The day before, she had told inspectors the facility's MDS nurse, a registered nurse scheduled Monday through Friday from 8 a.m. to 5 p.m., was the person they relied on to satisfy the eight-consecutive-hour RN coverage requirement on weekdays.
That left weekends.
On January 13, January 14, and February 17 of 2024, the facility could not demonstrate that any registered nurse had been on duty for eight consecutive hours. The MDS nurse was not scheduled those days. No other coverage was documented. The timecard for February 3 was never produced at all, leaving that day unverifiable.
The business office manager, identified in the report as BOM C, told inspectors during the entrance conference that the DON worked 36 hours per week and was paid hourly. She also confirmed the facility had no nurse staffing waivers, meaning no regulatory exception had been granted to allow reduced coverage.
The facility's own nursing staffing policy, undated, states that a registered nurse must be on duty for at least eight consecutive hours a day, seven days a week. On at least three documented days in the first quarter of 2024, that didn't happen.
The inspection was completed March 12, 2025. Inspectors classified the harm level as minimal harm or potential for actual harm, and noted the deficiencies affected many residents.
What the records show is a facility where the person responsible for overseeing nursing care was present, on average, for roughly three hours a day across a six-month stretch, while the people running the building believed the number was nearly double that. Nobody checked. The timecards existed. The discrepancy was not discovered internally.
For the residents of Five Counties Nursing Home, the practical meaning of reduced director of nursing hours is a facility where oversight of medication administration, wound care, care planning, and staffing decisions falls to whoever is present. When the person whose job is to supervise that work is there 23 hours a week instead of 36, the gap doesn't disappear. It gets filled by someone else, or it doesn't get filled at all.
The MDS nurse's schedule, 8 to 5 on weekdays, covered the RN presence requirement on those days. On the three days inspectors flagged in January and February 2024, it was a Saturday, a Sunday, and a Sunday. No one was scheduled. No waiver had been obtained. The facility's own policy said seven days a week.
Administrator A confirmed all of this in her interview on the evening of March 11. She said there was no RN scheduled for eight consecutive hours on those three days. She said the DON had worked on February 3, the day the timecard was missing, but she could not produce documentation to support it.
The inspection report does not say what happened on those three uncovered days, who made clinical decisions, or whether anything went wrong. It records only the absence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Five Counties Nursing Home from 2025-03-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 10, 2026 · Our methodology
Five Counties Nursing Home in LEMMON, SD was cited for violations during a health inspection on March 12, 2025.
Inspectors reviewed DON B's timecards for weeks scattered between July and December 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.