Nursing home report card · Lemmon, SD
Five Counties Nursing Home
405 6th Avenue West, Lemmon, SD 57638
Quick summary
Below-average Medicare rating
Overall rating is 1 of 5 stars. Its health-inspection rating is 1 of 5. Read the dated inspection findings and separate staffing and care ratings below.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- May 7, 2026
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Among the lowest Medicare ratings
Based on problems found during health inspections.
Among the lowest Medicare ratings
Based on staffing levels and related measures.
Below-average Medicare rating
Based on reported health and care results.
Among the lowest Medicare ratings
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 435090
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Caused actual harm · isolated case
Apr 9, 2025 · Inspection rule 0760
Ensure that residents are free from significant medication errors.
Caused actual harm · isolated case
Apr 9, 2025 · Inspection rule 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Could have caused harm · isolated case
May 7, 2026 · Inspection rule 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 45 minutes per resident per day
about 2 hr 54 min per resident per day
about 37 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 1 stars
- Health inspection rating: 1 stars
- Staffing rating: 2 stars
- Registered nurse time per resident: 0.76 hours/day
- Total nurse time per resident: 2.9 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; South Dakota averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Overall star rating is 2 or lower
- Health inspection rating is 2 stars or lower
- Inspectors have listed an unusually high number of problems
- CMS has fined this home in the recent reporting period
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Caused actual harm2 citations
- Could have caused harm35 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 37
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as Non profit - Corporation.
- We do not have individual owner names for this home.
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
May 7, 20264 findings
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0550 · code D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0554 · code D
Allow residents to self-administer drugs if determined clinically appropriate.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
May 15, 20251 finding
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
April 9, 20255 findings
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Pharmacy Service problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code G
Ensure that residents are free from significant medication errors.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code E
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.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code D
Respond appropriately to all alleged violations.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code D
Ensure services provided by the nursing facility meet professional standards of quality.
March 12, 202521 findings
- Nursing and Physician Services problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0727 · code F
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.
- Nursing and Physician Services problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0732 · code F
Post nurse staffing information every day.
- Pharmacy Service problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0847 · code F
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code E
Ensure services provided by the nursing facility meet professional standards of quality.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0699 · code E
Provide care or services that was trauma informed and/or culturally competent.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code D
Respond appropriately to all alleged violations.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0758 · code D
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…
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0582 · code E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0583 · code E
Keep residents' personal and medical records private and confidential.
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0655 · code E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0700 · code E
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 r…
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code E
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.
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0909 · code E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
- Nursing and Physician Services problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0725 · code F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0835 · code F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0837 · code F
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.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0848 · code F
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0851 · code F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0865 · code F
Have a plan that describes the process for conducting QAPI and QAA activities.
January 22, 20251 finding
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
December 6, 20235 findings
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0625 · code D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0758 · code D
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…
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code E
Ensure services provided by the nursing facility meet professional standards of quality.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0678 · code E
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0692 · code E
Provide enough food/fluids to maintain a resident's health.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Fine · Mar 12, 2025$20,703
Related topics
Questions about Five Counties Nursing Home
What is Five Counties Nursing Home's Medicare star rating?
Has Five Counties Nursing Home been fined?
Does Five Counties Nursing Home have a Medicare abuse warning?
How does Five Counties Nursing Home compare with other nursing homes in South Dakota?
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