Five Counties Nursing Home
Five Counties Nursing Home in LEMMON, SD — inspection on March 12, 2025.
Found 22 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of resident 41's EMR revealed:
*Her last covered day of Medicare Part A skilled services was 12/23/24. *The section of the SNF ABN form Beginning on with a blank for the date that stated when her Medicare coverage ended was missing and appeared to have been whited out. *The date box had a typewritten date of 12/20/24.
- Interview on 3/11/25 at 10:35 a.m. with administrator A regarding the SNF ABN Forms revealed:
*She agreed that the section of the form that included the date Medicare coverage ended was missing from residents 10, 33, and 41's forms and appeared to have been whited out. *She was unsure why the SNF ABN forms for residents 10 and 33, who were cognitively intact, had been telephone signed by a family member and not the resident. *She stated that the previous DON P had been responsible for the SNF ABN forms at the time they were provided to residents 10, 33, and 41.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
-Signature
-Consent -Do Not Consent *The last page of the policy indicated a sign was to be posted that included THIS ROOM CONTAINS A VIDEO MONITORING DEVICE.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
cause physical harm, pain, or mental anguish.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
indicated his 8/30/24 baseline care plan had included focus areas of: -Activities of daily living (ADL) assistance with transferring, ambulating, locomotion, dressing, personal hygiene, eating, toilet use, and bathing. -Visual impairment related to his severely impaired visual function. -Communication problems related to his hearing impairment. -Mobility assistance related to his history of falls, visual impairment, and gait/balance problems. *His 9/3/24 Brief Interview of Mental Status (BIMS) assessment score was 8, which indicated his cognition was moderately impaired. *There was no documentation that indicated the interim/baseline care plan had been reviewed or given to the resident or his representative.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Review of the provider's undated Physician Standing Orders policy revealed the following: *Diabetic Management: -Notify provider if two BG [blood glucose] results are < [less than] 70 or > [greater than] 400 in a 24-hour period and/or change in condition; if no condition change, notify provider on the next business day. *Hypoglycemia (BG <70) *If resident is symptomatic, conscious, and able to swallow or has a feeding tube: -Administer 6 ox [ounces] fruit juice, milk, regular pop, or other high carbohydrate beverage (eg.
Ensure, Boost) orally or via feeding tube. -Repeat BG after 15 minutes; if <70 repeat above intervention. -If after 2 attempts to treat and BG still <70, notify provider. *Once resident is stable, recheck BG after 60 minutes. *Communicate occurrence of any hypoglycemic event to provider the next business day.
Review of the provider's undated Medication Management policy revealed, Medications are administered in accordance with written orders of the attending physician or physician extender.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Review of resident 36's EMR revealed:
*She was admitted on [DATE]. *Her 3/5/25 BIMS assessment score was 1, which indicated severe cognitive impairment. *Her diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. *There was no trauma-informed care assessment in resident 36's EMR.
Review of resident 36's 3/9/24 care plan revealed it did not contain a focus area or interventions for her behaviors and vocalizations.
Interview on 3/12/25 at 11:08 a.m. with administrator A regarding trauma-informed care revealed: *The provider did not complete an assessment for any residents on admit or re-admission. *The provider did not assess or reassess any residents for trauma-informed care.
Review of the provider's 4/20/19 Trauma Informed Care Plan and Procedure revealed: *Trauma-Informed Care 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. *Trauma Informed care will be addressed in the care plan of noted residents.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
-Ensure ongoing assessment and maintenance of resident bed assist bar use.
*Procedure: -1.
Prior to installation of bed assist bar, charge nurse or designee must complete Assistive Device Assessment to determine appropriateness of using bed assist bars. -2.
Decision to install bed assist bar shall be made based on the following information assessed in the Assistive Device Assessment: --a.
Determine the reason for the bed assist bar and if it is likely to [for] the resident [to] meet his or her needs. --b.
Evaluation of any bed assist bar alternatives attempted that failed to meet the resident's needs prior to use and installation and alternatives considered but not attempted because they were considered to be inappropriate. --c.
Assess the resident for risks to safety with use of bed assist bar including cognition, mobility, communication, etc. -Bed rail/assist bar evaluation form will be completed quarterly to assess appropriateness and need for continued use.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Review of the provider's undated Nursing Staffing and Posting policy revealed The facility is required to provide licensed nursing staff 24 hours a day (except when waived), along with other nursing personnel, including but not limited to nurse aides.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Review of the RN staff timecards for fiscal year 2024 revealed: *The DON timecard for 2/3/24 was not produced by the provider to verify hours worked. *RN coverage for eight consecutive hours could not be verified for 1/13/24, 1/14/24, and 2/17/24.
- Interview on 3/11/25 at 6:00 p.m. with administrator A revealed:
*The Minimum Data Set (MDS) nurse was scheduled from 8:00 a.m. to 5:00 p.m.
Monday through Friday during quarter two of fiscal year 2024. *She was salaried. *The MDS nurse was a RN and would be considered to cover the requirement for an RN eight consecutive hours per day on the days she worked. *There was no RN scheduled for eight consecutive hours on 1/13/24, 1/14/24, and 2/17/24. *DON B had worked on 2/3/24.
- Interview on 3/12/25 at 7:47 a.m. with administrator A revealed she thought DON B worked
between 36 and 40 hours per week.
Review of DON B's timecards revealed during 16 weeks of randomly selected timecards between July and December 2024, DON B averaged 23.125 hours per week.
Review of the provider's undated Nursing Staffing and Posting policy revealed, The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
--Facility's current resident census
--The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: ---Registered Nurses ---Licensed Practical Nurses/Licensed Vocational Nurses ---Certified Nurse Aides -The information posted will be: --Presented in a clear and readable format. --In a prominent place readily accessible to residents, staff, and visitors.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
they are complete the count sheet should be sent to medical records and kept for 3 years.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Review of the provider's undated Antipsychotic Medication Policy revealed the following: *Nursing will monitor antipsychotic drug use daily noting any adverse effects such as increased somnolence (excessive sleepiness), functional decline, cardia [cardiac] arrhythmias (abnormal heart rhythm), parkinsonism (characterized by the same motor symptoms as Parkinson's disease), akathisia (movement disorder characterized by a feeling of restlessness and an inability to sit still), tardive dyskinesia (repetitive, involuntary movement disorder), dystonia (involuntary, sustained muscle contractions), anticholinergic effects (side effects caused by medications that block the action of the neurotransmitter acetylcholine), orthostatic hypotension (low blood pressure after standing up from a sitting or lying position) and cerebrovascular evens [events] (conditions that affect the blood vessels in the brain) which can include stroke, TIA [transient ischemic attack] (a mini-stroke), and heart failure. If any of these adverse effects are noted, the charge nurse will chart detailing in progress noted [notes] in [EMR] and notify primary care physician of findings. *AIMS assessment will be performed every 3-6 months and quarterly psychotropic drug assessment will be performed on a quarterly basis with the MDS assessment schedule and any changes will be reported to the physician. *Efforts to reduce dosage or to discontinue use of antipsychotics will be ongoing, as appropriate, for the clinical situation.
Use will be reviewed at care conferences and recommendations for gradual dose reduction (GDR) will be given to physician, unless clinically contraindicated, to assess effectiveness and/or need for continues [continued] use of antipsychotic.
Pharmacy consultant will review [antipsychotic] use and offer recommendations as indicated. *Definition of Clinically Contraindicated for Antipsychotics: -The physician has documented the clinical rationale for why an additional attempted dose reduction would likely impair the resident's function or increase distressed behavior. -For [a] resident with a psychiatric disorder other than dementia: --a. If the continues [continued] use in [is] in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any additional attempted dose reduction would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder. --b. If the resident's symptoms returned or worsened after the most recent GDR attempt and the physician has documented the clinical rationale for why any additional attempted dose reduction would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder.
Review of the provider's undated Cart Organization and Proper Medication Storage policy revealed: *When opening any Multi-Dose container/items-they should be dated with the open date immediately.
Review of the provider's undated Medication Storage and Labeling policy revealed the following: *Labels for multi-use vials must include: -The date the vial was initially opened or accessed (needle-punctured); -All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. -Labels for medications designed for multiple administrations (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
*Cleaned equipment and utensils must be stored as follows: -In a clean, dry location; -Where they are not exposed to splash, dust, or other contamination; -In a self-draining position that permits air drying; and -Either covered or inverted. *After sanitizing, equipment and utensils must be air-dried or may be used after adequate draining.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Review of the provider's undated job description for the administrator revealed: *Summary: Administers, directs and coordinates all activities of the care center to carry out its objectives as to the care of the individuals who need nursing care . *Essential Duties included: -Coordinates and integrates the total overall program of the facility. -Make sure residents are meeting their highest level of professional care needed. -Develops and monitors all departments within the facility to meet the standards put forth by the governing board, management, and state and federal regulations.
Review of the provider's 10/30/15 job description for the director of nursing revealed: *Summary: This individual directs the licensed and non-licensed staff who provide health care and nursing services to residents of the facility.
The Director of Nursing's primary responsibility is to ensure the provision of quality nursing care on a 24-hour basis to the residents of the care center in accordance with Federal, State and Local standards and regulations. *Essential Duties included: -Monitors the staffing levels of various nursing sections . -Develops and directs nursing services objectives, policies and procedures. -Assures that there is compliance with the regulations pertaining to care plans and resident assessments. -Collaborates with outside providers such as . pharmacy companies to enhance the quality of care for the residents.
Refer to F-F582, F-F583, F-F610, F-F655, F-F658, F-F699, F-F700, F-F725, F-F727, F-F732, F-F755, F-F761, F-F812, F-F847, F-F865, and F-F909.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
*Ensuring privacy and signage had been maintained for two residents (9 and 21) with audio/video monitoring devices in their rooms. *Implementing an effective performance improvement plan and quality assurance program.
Refer to F-F582, F-F583, F-F610, F-F655, F-F658, F-F699, F-F700, F-F725, F-F727, F-F732, F-F755, F-F758, F-F761, F-F812, F-F835, F-F847, F-F848, F-F851, F-F865, and F-F909.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
representative was not required to enter into the agreement as a condition of admission to the
-Administrator A agreed that was not clearly stated in the agreement.
-Administrator A stated it was a poorly written agreement.
Further interview that day with administrator A at 8:30 a.m. after reviewing the requested arbitration agreements for three residents (21, 23, and 24) and a handwritten note from SSD E revealed: *On 11/8/22, SSD E was provided notice to add the Arbitration of Disputes form to the admission Agreement packet. *Administrator A confirmed that residents who were admitted to the facility prior to 11/8/22 had not entered into the arbitration agreement.
Interview on 3/11/25 at 9:51 a.m. with SSD E regarding requested arbitration agreements revealed: *She confirmed that prior to 11/8/22 the residents admitted to the facility had not signed an arbitration agreement upon their admission. *Those residents had not been asked to sign the arbitration agreement after 11/8/22, when the arbitration agreement was added to the admission agreement packet. *A printed email, that she provided, indicated on 11/8/22 at 1:48 p.m. the administrator of the facility, at that time, had e-mailed the Arbitration of Disputes as an attachment with the message Please include this in your admission packet. -She confirmed that was her notice and that she had received no training on that form or the arbitration process.
Interview on 3/11/25 at 1:10 p.m. with administrator A regarding the requested policy on arbitration agreements revealed the provider did not have such a policy.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
*Provided for the selection of a neutral arbitrator agreed upon by both parties. *Provided for a location that was convenient for both parties for an arbitration dispute.
Findings include:
- Interview and record review of the provider's one-page arbitration agreement on 3/10/25 at 5:43
p.m. with administrator A revealed that the agreement had not included: *The arbitration organization's name and how to contact that organization. *For the provision of the selection of a neutral arbitrator agreed upon by both parties. *For the provision of a location that was convenient for both parties for an arbitration dispute. *Administrator A agreed with those findings above.
Interview on 3/11/25 at 1:10 p.m. with administrator A regarding the arbitration agreement revealed: *The provider had no policy regarding arbitration agreements. *She agreed the arbitration agreement was poorly written.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
indicator that 100% of the information was submitted and the report had been accepted. -She was not aware that the indicator only provided notification that the information submitted was accepted at 100% and not if that data was accurate to actual hours worked by staff.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
delivery . by ensuring our data collection tools and monitoring systems are in place and are consistent
*The scope of the QAPI program encompasses all types and segments of care and services that
*The governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program .
Refer to F-F655, F-F700, F-F725, F-F727, F-F732, F-F755, F-F761, F-F847, F-F848, F-F851, and F-F909.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Review of the provider's undated Bed Assist Bar Policy & Procedure revealed: *Policy: -Ensure ongoing assessment and maintenance of resident bed assist bar use. *Procedure: -4.
Initial actions to prevent deaths and injuries from entrapment and/or falls from bed assist bars: --a.
Ensure bed dimensions are appropriate for resident. --b.
Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed. --c.
Check with the manufacturer(s) to make sure the bed assist bar, mattress, and bed frame are compatible. --d.
Install bed assist bars using the manufacturer's instructions and specifications to ensure a proper fit. -5.
Inspect and regularly check the mattress and bed assist bar for areas of possible entrapment. --a.
Regardless of mattress width, length, and/or depth, the bed frame, bed assist bar, and mattress should leave no gap wide enough to entrap a resident's head or body. --b.
Check bed assist bars regularly to make sure they are still installed correctly as bars may shift or loosen of loosen over time. --c.
Follow manufacturer equipment alerts and recalls. --d.
Conduct routine preventative maintenance of beds and bed assist bars to ensure they meet current safety standards and are not in need of repair.
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Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
Observation on 3/9/25 at 2:31 p.m. of resident 36 revealed she had two quarter-length side rails in the up position at the head of her bed.
2.
Observation on 3/9/25 at 2:32 p.m. of resident 24 revealed she had two quarter-length side rails in the up position at the head of her bed.
3.
Observation on 3/9/25 at 2:36 p.m. of resident 9 revealed he had two quarter-length side rails in the up position at the head of his bed.
4.
Observation on 3/9/25 at 3:42 p.m. of resident 5 revealed she had two quarter-length side rails in the up position at the head of her bed.
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5.
Observations on 3/9/25 between 3:48 p.m. and 5:30 p.m. and on 3/10/24 between 8:12 a.m. and 11:00 a. m. of sampled resident rooms revealed 2, 3, 5, 6, 9, 13, 16, 21, 23, 24, 25, 36, and 142 had quarter-length side rails on one or both sides of their beds.
6.
Interview on 3/11/25 at 3:09 p.m. with maintenance director F regarding safety and preventative maintenance of side rail on residents' beds revealed:
*The physical therapists initiated the use of side rails for residents.
*He was aware of one bed with side rails attached, the bed in room [ROOM NUMBER].
-That resident was not an identified sampled resident.
-That resident had purchased his own bed, and it had a box spring and metal frame, and on 5/2/24 maintenance director F had installed side rails on that bed.
-He monitored only that residents' bed and the side rails attached to it monthly for safety.
*He thought all other residents' beds with side rails in the up position were for the remote of the electronic bed.
*He was not aware the other residents' beds with side rails attached were being assessed by the nursing staff for use as side rails.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 435090 B.
Wing 03/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.