The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited April 2025 — isolated incident, actual harm.
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F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
Five Counties Nursing Home
LEMMON, SD · Medicare-certified · 38 beds
Needs attention
Special Focus candidateNon-profit
1 of 5 overall
Five Counties Nursing Home in Lemmon, SD has a 1-star overall rating, with 1-star scores for health inspections, staffing, and quality measures. It is a special focus facility/SFF candidate and was cited for issues including pressure ulcer care, medication errors, and not having enough nursing staff; it also had $20,703 in fines in the last 24 months.
Facility ratings
Health inspections
Staffing
Quality measures
Last inspection: May 15, 2025Penalties, last 24 months: $20,703special focus facility
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports not reported.
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
17.4%Worsening
Residents with a fall causing major injury
10.2%Improving
Residents with pressure ulcers (bedsores)
3.3%Steady
Residents with a urinary tract infection
5.9%Improving
Residents who lost too much weight
6.6%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
25%Improving
Residents whose ability to walk got worse
23.4%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
14.6%Worsening
Residents with a long-term catheter
3.4%Steady
Residents with new or worsening incontinence
24.7%Worsening
Residents with depressive symptoms
0.8%Steady
Long-stay residents given the seasonal flu vaccine
95.2%Steady
Long-stay residents given the pneumonia vaccine
83.9%Worsening
Short-stay residents given the pneumonia vaccine
72.2%Steady
What the inspectors found
The nursing home failed to ensure residents were free from significant medication errors. Cited April 2025 — isolated incident, actual harm.
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F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: G
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited March 2025 — widespread issue, potential for harm.
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F-Tag 725 — 42 CFR §483.35 — S/S: F
The home failed to have a registered nurse on duty enough hours each day and to keep a registered nurse as the full-time director of nursing. Cited March 2025 — widespread issue, potential for harm.
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F-Tag 727 — 42 CFR §483.35 — S/S: F
The nursing home failed to post its nurse staffing information every day, so families could not easily see daily staffing levels. Cited March 2025 — widespread issue, potential for harm.
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F-Tag 732 — 42 CFR §483.35(i) — S/S: F
Recent history
- INSPECTION
Health inspection found 1 health deficiency.
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- INSPECTION
Health inspection found 5 health deficiencies.
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- PENALTY
A federal fine of $20,703 was recorded.
- INSPECTION
Health inspection found 21 health deficiencies.
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Penalties & enforcement
On record with Medicare: 1 fine · $20,703 in total fines.
- $20,703
Federal fine
Mar 12, 2025
Operator & ownership
- Ownership
- Non profit - Corporation
- Occupancy
- 30.2 residents on an average day (79% of 38 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 30 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.