Five Counties Nursing Home
405 6th Avenue West · Lemmon, SD · 57638 · 6053743871
38 certified beds Non profit - Corporation
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
- Inspection results are getting worse cycle over cycle, not better.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $20,703 |
Inspection citations (34 in the current record)
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Potential for harm · D May 15, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 27, 2025 · Quality of Life and Care
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Actual harm · G April 9, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 2, 2025 · Quality of Life and Care
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Actual harm · G April 9, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected May 2, 2025 · Pharmacy Service
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Potential for harm · D April 9, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected May 27, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 9, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected May 27, 2025 · Resident Assessment and Care Planning
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Potential for harm · E April 9, 2025 · found via complaint
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected May 2, 2025 · Pharmacy Service
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Potential for harm · E March 12, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected April 26, 2025 · Resident Rights
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Potential for harm · E March 12, 2025
Keep residents' personal and medical records private and confidential.
Corrected April 26, 2025 · Resident Rights
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Potential for harm · D March 12, 2025
Respond appropriately to all alleged violations.
Corrected May 27, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 12, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected April 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · E March 12, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · E March 12, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected April 26, 2025 · Quality of Life and Care
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Potential for harm · E March 12, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected May 8, 2025 · Quality of Life and Care
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Potential for harm · F March 12, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected April 26, 2025 · Nursing and Physician Services
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Potential for harm · F March 12, 2025
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected April 26, 2025 · Nursing and Physician Services
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Potential for harm · F March 12, 2025
Post nurse staffing information every day.
Corrected April 26, 2025 · Nursing and Physician Services
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Potential for harm · F March 12, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 27, 2025 · Pharmacy Service
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Potential for harm · D March 12, 2025
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected April 26, 2025 · Pharmacy Service
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Potential for harm · E March 12, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected April 26, 2025 · Pharmacy Service
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Potential for harm · F March 12, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 26, 2025 · Nutrition and Dietary
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Potential for harm · F March 12, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected April 26, 2025 · Administration
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Potential for harm · F March 12, 2025
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected April 26, 2025 · Administration
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Potential for harm · F March 12, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected May 7, 2025 · Administration
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Potential for harm · F March 12, 2025
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected May 7, 2025 · Administration
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Potential for harm · F March 12, 2025
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected April 26, 2025 · Administration
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 12, 2025 | Fine | $20,703 |
Better-scoring options nearby
No better-scoring facility within 25 miles in the current data. See the whole state.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435090 · certified since September 1, 1995. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.