Five Counties Nursing Home: Trauma Care Failures - SD
The woman, identified in inspection records only as Resident 36, scored a 1 on her cognitive assessment in early March, the lowest possible indicator of cognitive function, reflecting severe impairment. Her diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. She had been living at the facility since at least the date of her admission on file.
Her care plan, last reviewed in March 2024, contained no focus area for her behaviors. No interventions. Nothing about the repeated back-and-forth movement that inspectors observed and documented.
And there was no trauma-informed care assessment anywhere in her records.
That last part, it turned out, was true for every single person living at Five Counties.
When inspectors sat down with the facility's administrator on the morning of March 12, 2025, the administrator confirmed it directly: the provider had not completed a trauma-informed care assessment for any resident on admission or readmission. Not for Resident 36. Not for anyone else. The assessments simply had not been done.
This was not a gap in paperwork for one difficult case. It was a facility-wide absence.
Five Counties had its own written policy on the subject, dated April 20, 2019. The document described trauma-informed care as an approach that "understands and considers the pervasive nature of trauma and promotes environments of healing and recovery rather than practices and services that may inadvertently re-traumatize." The policy stated that trauma-informed care would be addressed in the care plans of residents identified as needing it.
Six years after writing that policy, the facility had not used it.
The relevance to Resident 36 is not abstract. A person with a cognitive score of 1 cannot reliably communicate distress, explain her history, or tell a caregiver what is frightening her. She cannot say whether the wheelchair movement is habit, anxiety, a response to something in her environment, or the residue of something that happened to her long before she arrived at the facility. A trauma-informed assessment is one of the few structured tools available to staff trying to understand behavior in a person who can no longer explain herself.
Without it, the behavior gets noted. It does not get understood.
Inspectors classified the violation at the level of minimal harm or potential for actual harm, affecting some residents. That classification reflects the regulatory framework's judgment about documented injury, not about what the absence of an assessment means over time for a woman who scores a 1 on cognition and spends her days moving in and out of her room.
Five Counties Nursing Home sits on 6th Avenue West in Lemmon, a small city in Perkins County in northwestern South Dakota. The inspection was conducted on March 12, 2025.
The administrator did not dispute what inspectors found. The assessments had not been done. The care plan had no interventions for the behaviors inspectors observed. The policy existed on paper and had existed for years.
Resident 36 kept moving. In and out. In and out. The records do not say whether anyone asked her what she was looking for.
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.
Her diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety.
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.