Five Counties Nursing Home
Lemmon, South Dakota · CCN 435090
21 surveys since 2011. The first finding at harm level was recorded in 2015.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 101
- Surveys
- 21
- Harm or worse
- 12
- Immediate jeopardy
- 8
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 38
- Ownership
- Non profit - Corporation
- Chain
- Independent
- County
- Perkins · rural
- Medicare-certified since
- 1995
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 2
- Quality measures
- 1
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 48 not-for-profit facilities with fewer than 66 beds in South Dakota.
Last survey on record
May 7, 2026
186 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 2.90 | 3.73 |
| Registered-nurse hours per resident day | 0.76 | — |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $20,703 across 1 penalty
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G25.4% | H— | I— |
| No harm, potential for more than minimal | D1027.0% | E1437.8% | F1129.7% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6583×
Ensure services provided by the nursing facility meet professional standards of quality.
- F6102×
Respond appropriately to all alleged violations.
- F6892×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F7582×
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.
- F7612×
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.
In the surveyor’s words
From the most serious findings on record at Five Counties Nursing Home, in the surveyor’s own words.
- Actual harm, isolatedF686Apr 9, 2025
Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer prevention interventions for one of one sampled resident (1) identified at risk for pressure ulcers who developed a pressure ulcer to her spinal area. Findings include: 1. Observation on 4/7/25 at 2:48 p.m. of resident 1 in her room revealed: *She was lying on her back in her bed. *She was very thin in appearance. *There were Prevalon boots (cushioned boots used to decrease heel pressure) on the floor next to her closet. *There was a cushion in the seat of her wheelchair. 2. […]
- Actual harm, isolatedF760Apr 9, 2025
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure one of one sampled resident (1) was free from a significant medication error that involved a controlled medication (medications with risk for abuse and addiction) that she did not have orders to receive. She required an emergency room (ER) evaluation and treatment related to a change in her condition. Findings include: 1. […]
- No harm, potential for more than minimal, widespreadF725Mar 12, 2025
Based on interview, Payroll Based Journal (PBJ) record review, employee timecard review, and policy review, the provider failed to ensure licensed nursing coverage for 24 hours a day for three federal fiscal quarters (Quarter 2, 1/1/24 through 3/31/24; Quarter 3, 4/1/24 through 6/30/24; and Quarter 4, 7/1/24 through 9/30/24). Findings include: 1. Interview on 3/9/25 at 2:08 p.m. with business office manager C during the entrance conference revealed the provider did not have any licensed nurse staffing waivers. 2. Interview on 3/9/25 at 3:42 p.m. with resident 5 revealed she had been told by staff members on multiple occasions they were short of nurses. 3. […]
- No harm, potential for more than minimal, widespreadF727Mar 12, 2025
Based on Payroll Based Journal (PBJ) reports, interview, staff timecard review, and policy review, the provider failed to ensure: *A registered nurse (RN) had been scheduled for eight consecutive hours of coverage for four days in quarter two (January 1 through March 31) of fiscal year 2024. *There was a full-time director of nursing (DON) for 16 randomly selected weeks between July and December 2024. 1. Interview on 3/9/35 at 2:08 p.m. with business office manager (BOM) C during the entrance conference revealed: *The provider did not have any nurse staffing waivers. *She stated the DON worked 36 hours per week. *The DON was paid hourly. 2. […]
- No harm, potential for more than minimal, widespreadF732Mar 12, 2025
Based on observation, interview, and record review, the provider failed to post the required daily nurse staffing information in a prominent location that was readily accessible to residents and visitors and to include the actual hours worked of nursing staff. Findings include: 1. Observation 3/12/25 at 8:00 a.m. of the posted nurse staffing information revealed: *It was posted on a board near the nurse's station. *It would not be readable to a resident or visitor in a wheelchair at the height it was posted. *There were three categories of staff listed on the sheet: RN (registered nurse), LPN (licensed practical nurse), and CNA (certified nursing assistant). *Under the LPN and CNA category the number of those staff scheduled for the day was listed by shift. […]
Read 30 findings in full →The most serious and the most recent: 30 of 101 on record.
Every survey on record
FindingsAt actual harm or above
- May 7, 2026Standard4 findings
- May 15, 2025Complaint1 finding
- Apr 9, 2025Complaint5 findings · 2 harm
- Mar 12, 2025Standard21 findings
- Jan 22, 2025Complaint1 finding
- Dec 6, 2023Standard5 findings
- Nov 3, 2022Standard1 finding
- Jun 9, 2022Complaint1 finding
Show the 13 earlier surveys
- May 6, 2021Standard2 findings
- Jan 12, 2021Infection control1 finding
- May 15, 2019Standard4 findings
- Feb 8, 2018Standard4 findings
- Jun 27, 2017Complaint1 finding
- Dec 14, 2016Standard6 findings · 1 harm
- Oct 26, 2016Complaint1 finding
- Sep 23, 2015Standard9 findings
- Mar 4, 2015Complaint9 findings · 9 harm
- Jul 24, 2014Standard6 findings
- Jun 12, 2013—7 findings
- Apr 18, 2012—9 findings
- Mar 16, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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