Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Five Counties Nursing Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and a history of exit-seeking behavior was able to leave the facility unsupervised by entering a door keypad code she had overheard, due to inadequate supervision and lack of secure environmental controls. The resident was outside for an unknown period before being let back in by a staff member. Staff interviews revealed inconsistent elopement drills, lack of documentation for code changes, and absence of a photo identification system for at-risk residents, all contrary to facility policy.
A resident at risk for pressure ulcers developed a spinal pressure ulcer after staff failed to consistently implement physician-ordered and care-planned interventions, including use of a pressure-relieving mattress and a specialized wheelchair cushion. Staff were unaware of or did not follow the care plan, and when a pressure-relieving cushion was removed from the wheelchair, no alternative was provided. The facility's skin care protocol was outdated and not followed, and communication gaps existed regarding the resident's nutritional and skin care needs.
A resident with moderate cognitive impairment and multiple chronic conditions was found unresponsive and required emergency care after receiving a benzodiazepine that was not prescribed. Despite staff interviews and a review of medication administration practices, the facility could not determine how the resident ingested the controlled medication. The resident's drug screen was positive for benzodiazepines, and facility policies requiring verification and safe administration of medications were not effectively followed, resulting in a significant medication error.
Medications, including controlled substances, were not securely stored, with keys left unattended on a medication cart and a medication cart found unlocked and unsupervised. The medication room was accessible to unauthorized staff, including the administrator and maintenance director, who both knew the keypad code and entered the room alone. A refrigerator in the medication room contained an unlocked lock box with liquid lorazepam, a controlled medication, further violating facility policy that restricts access to narcotics to licensed staff and the DON.
A resident with moderate cognitive impairment and multiple medical conditions was found with a facial bruise of unknown origin, which was not documented or investigated by staff as required. Multiple CNAs observed the bruise but did not ensure it was reported to the DON or administrator, and there was no evidence of a thorough investigation or timely notification to the state health department, despite facility policy mandating such actions.
A resident with moderate cognitive impairment and hyponatremia did not have a physician-ordered fluid restriction effectively implemented or accurately documented, and a physician-ordered BMP lab test was not completed. Staff were unclear about the fluid restriction order, inconsistently documented fluid intake, and did not always count all sources of fluids. The facility could not provide a fluid restriction policy or verify communication of the restriction during shift reports.
A resident with a history of falls was not referred to physical therapy after multiple falls, contrary to facility policy. Additionally, five residents with various medical conditions had inconsistent documentation of vital signs, with previous readings recorded instead of current ones. The facility's policy required daily documentation of vital signs for Medicare reimbursement, but significant gaps were found in the records.
Failure to Prevent Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
A cognitively impaired resident with a history of dementia, Alzheimer's disease, schizophrenia, and agitation, who was identified as being at risk for elopement, was able to exit the facility without staff knowledge. The resident independently entered a door keypad code to unlock an exit door and left the building. The code had been overheard by the resident, and there was no documentation of when door codes were changed or how access to the codes was controlled. The resident was outside for an unknown period before returning to the building after ringing the front doorbell and being let in by a staff member. The resident's care plan and risk assessments indicated fluctuating levels of elopement risk, with interventions such as window alarms, AirTags in shoes, and previous use of a wearable tech device, which the resident refused to use. Despite being identified as high risk for elopement, the facility did not ensure that environmental controls, such as secure door codes and effective monitoring, were in place to prevent the resident from leaving unsupervised. Staff interviews revealed a lack of routine elopement drills, inconsistent documentation of code changes, and absence of a photo book or other identification system for at-risk residents at the reception desk. Facility policy required regular elopement risk assessments, implementation of risk reduction strategies, and environmental controls, including secure door codes and monitoring systems. However, the policy was not consistently followed, as confirmed by the administrator. There were no cameras to verify the resident's exit, and staff and administration were uncertain about the frequency of code changes and the dates of previous elopements. The failure to maintain secure access controls and provide adequate supervision allowed the resident to elope undetected.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident identified as at risk for pressure ulcers developed a pressure ulcer on her spinal area due to the facility's failure to implement and maintain appropriate pressure ulcer prevention interventions. The resident, who had moderate cognitive impairment and was underweight with a BMI of 17, was dependent on staff for activities of daily living and had a history of limited mobility. Physician orders and the care plan included the use of a pressure-relieving mattress, a pressure-relieving cushion in her wheelchair, frequent repositioning, offloading of heels, and weekly skin assessments. However, observations revealed that the resident did not have a specialized mattress on her bed, and the sacral dish cushion intended for her wheelchair was not in use. Staff interviews confirmed a lack of awareness and implementation of these interventions, with some staff unaware of the need for the sacral dish cushion and others noting its removal without replacement. The resident's care plan and kardex specified interventions such as the use of assist bars for repositioning, education on offloading pressure, and the use of specific cushions for pressure relief. Despite these documented interventions, staff reported that the resident was often noncompliant with repositioning and the use of wedges, preferring to lie on her back. The Prevalon boots, intended to offload heel pressure, were only recently implemented, and the specialized mattress was not present at the time of the pressure ulcer's development. Additionally, there was a lack of communication and follow-through regarding the removal of the sacral dish cushion by therapy, with no alternative pressure-relieving measures put in place. The facility's Nursing Skin Care Protocol required comprehensive assessment, documentation, and communication regarding skin issues, including notification of the dietary manager and registered dietician for nutritional assessment. However, the dietician's progress notes did not address the resident's skin condition or risk for pressure ulcers, and the protocol itself was found to be outdated and not reflective of current practices. The DON was not aware that staff were no longer using the sacral dish cushion, and there was no evidence that the required interventions were consistently implemented or monitored prior to the development of the pressure ulcer.
Resident Received Unprescribed Benzodiazepine Resulting in Hospitalization
Penalty
Summary
A facility failed to ensure that a resident was free from significant medication errors when a resident with moderate cognitive impairment and multiple medical diagnoses, including COPD, hypertension, and dementia, was found unresponsive and required emergency medical intervention. The resident was not prescribed any benzodiazepine medication, yet a drug screen at the emergency room revealed the presence of benzodiazepines in her system. The resident had received her scheduled medications, which did not include any benzodiazepines, from a certified nurse assistant/certified medication aide earlier that morning. Shortly after, she exhibited severe symptoms such as unresponsiveness, shaking, low blood pressure, and low oxygen saturation, necessitating ambulance transport to the hospital. The facility's investigation was unable to determine how the resident received the unprescribed benzodiazepine. Interviews with staff, including the medication aide who administered the morning medications, indicated that the resident was not near any other residents who were prescribed benzodiazepines at the time of administration. The resident's room was searched for unauthorized medications, and no evidence was found. The facility did not review the controlled medications in the medication carts after learning of the positive drug screen, and there was no indication that the medication could have been administered by hospital or ambulance staff. The resident's physician and consultant pharmacist confirmed that none of her prescribed medications could have caused a false positive for benzodiazepines. Facility policies required staff to follow the seven rights of medication administration and to ensure medications are administered only as prescribed, with verification of resident identity and observation of ingestion. Despite these policies, the facility could not identify the source of the medication error, and the resident's condition was directly linked to the ingestion of a benzodiazepine that was not ordered for her. The incident was reported to the state health department, and the facility acknowledged that a medication error had occurred, but the exact circumstances leading to the error remained undetermined.
Failure to Secure Medications and Restrict Access to Controlled Substances
Penalty
Summary
The facility failed to ensure that medications, including controlled substances, were securely stored and inaccessible to unauthorized individuals. Observations revealed that keys to a medication cart, which also opened a drawer containing controlled medications, were left unattended on an open shelf beside water cups, making them accessible to visitors and unauthorized persons. Additionally, a medication cart was found unlocked and unattended in a hallway, with no staff present in the vicinity. Further investigation showed that the medication room, secured by a keypad, was accessible to not only licensed nursing staff and certified medication aides, but also to the administrator and maintenance director, both of whom knew the keypad code. The maintenance director had entered the medication room alone on multiple occasions for non-medication-related tasks. Inside the medication room, a refrigerator containing a lock box with a bottle of liquid lorazepam (a controlled medication) was found unlocked, and the lock box itself was not secured. Interviews with staff, including the DON, confirmed that the administrator and maintenance director had access to the medication room and, consequently, to controlled medications, contrary to facility policy. The DON was aware that the refrigerator was not locked but was not aware that the lock box for controlled medications was also unsecured. Facility policies reviewed indicated that access to narcotics should be limited to licensed staff and the DON, and that medications should be stored in locations accessible only to designated staff, with medication carts kept locked when not in direct view of the administering staff.
Failure to Investigate and Report Facial Bruise of Unknown Origin
Penalty
Summary
The provider failed to ensure a thorough investigation and timely reporting to the South Dakota Department of Health regarding a facial bruise of unknown origin for a resident. The incident began when the resident was found unresponsive in the activity room, with a weak pulse and low blood pressure, and was subsequently transported to the emergency room. A drug screen revealed the presence of a benzodiazepine, which was not prescribed to the resident. The initial facility-reported incident did not mention any injuries or bruises. Subsequent observations and record reviews identified a bruise on the resident's forehead, which was not documented in the initial report or in skin assessments completed after the incident. Multiple staff members noticed the bruise at different times, but there was confusion and lack of clarity regarding when and to whom the bruise was reported. The director of nursing was not aware of the bruise, and there was no evidence that an investigation was conducted to determine its cause. Documentation of shift reports and communication about the injury was also lacking. The facility's policies require immediate reporting and thorough investigation of any suspected abuse, injury of unknown source, or unusual injuries, including prompt notification of management and documentation of findings. In this case, these procedures were not followed, as there was no documented investigation or timely notification to facility leadership or the state agency regarding the resident's facial bruise.
Failure to Implement and Document Physician-Ordered Fluid Restriction and Lab Test
Penalty
Summary
The facility failed to follow professional standards in implementing and documenting a physician-ordered fluid restriction and in completing a physician-ordered basic metabolic panel (BMP) lab test for a resident diagnosed with hyponatremia. The resident, who had moderate cognitive impairment and multiple diagnoses including hypertension, hypo-osmolality, and dementia, was ordered to have a daily fluid restriction of 40 ounces (1200 cc) and a BMP lab test. Review of the resident's medical record showed inconsistent and incomplete documentation of fluid intake, with daily totals often below the prescribed limit, and no evidence that all sources of fluid, such as supplements and Jello, were consistently counted or recorded. Observations revealed that the resident had access to fluids in her room, including a water pitcher and juice, despite the fluid restriction order. Staff interviews indicated confusion and lack of clarity regarding the fluid restriction order, with some staff unaware of the correct restriction amount and others not counting certain fluids, such as Jello, toward the daily total. Documentation responsibilities were inconsistently assigned between nursing, dietary, and activities staff, leading to gaps in tracking the resident's actual fluid intake. Additionally, there was no designated task in the electronic medical record for documenting the amount of supplement consumed, and CNA documentation of fluid intake was inconsistent or missing on some days. The facility also failed to complete the physician-ordered BMP lab test for the resident as scheduled. The director of nursing confirmed that the lab was not completed as ordered. Furthermore, the facility was unable to provide a fluid restriction policy when requested by surveyors, and there was no documentation verifying communication of the fluid restriction during nurse shift reports. These failures resulted in the facility not meeting professional standards of quality in the care of the resident.
Failure to Follow Post-Fall Management and Vital Signs Documentation Policies
Penalty
Summary
The provider failed to follow their policy regarding post-fall management for a resident who experienced multiple falls. The resident, who had a history of falls and required assistance for transfers, was not referred to physical therapy after falls on two occasions. The facility's policy required that physical therapy be notified of each fall, but there was no documentation of such referrals in the resident's medical record. Interviews with the physical therapist and the director of nursing confirmed that the therapy department was not notified, and the falls event checklist did not indicate that a referral was made. Additionally, the provider failed to ensure accurate and timely documentation of vital signs for five residents. The residents had various medical conditions, including hypertension, COPD, and heart failure, which necessitated regular monitoring of vital signs. However, the records showed that vital signs were not consistently checked and documented daily, with previous vital signs being recorded instead of current ones. This inconsistency was acknowledged by the director of nursing, who noted that the system might have been pulling from the last documented vital signs. The facility's policy required a full set of vital signs to be documented every 24 hours for Medicare reimbursement purposes. However, the review of the residents' electronic medical records revealed significant gaps in the documentation of vital signs, which did not align with the facility's policy. This deficiency in documentation was highlighted in a complaint report submitted to the South Dakota Department of Health, which raised concerns about the accuracy and timeliness of resident assessments at the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lemmon
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western Horizons Care Center | 25.5 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.