Cycle 1
Health 2025-03-12 · Fire 2025-03-12
27 health deficiencies
Top issue: Administration (6 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Lemmon, SD
Five Counties Nursing Home
1-star overall rating with 1-star inspections with Special Focus status with $31,850 in total fines with 27 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
405 6th Avenue West, Lemmon, SD
(605) 374-3871
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.19
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
88%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 6.35% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 27 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 23.08% |
53.69%
30.6 pts worse
|
Numerator 6 · Denominator 26 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 11 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 7.14% |
2.29%
4.8 pts worse
|
Numerator 2 · Denominator 28 · Adjusted rate 10.12% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 37 |
| Staff flu vaccination coverage | 12.5% |
42%
29.5 pts worse
|
Numerator 5 · Denominator 40 |
| Discharge function score | 42.31% |
56.45%
14.1 pts worse
|
Numerator 11 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.9
1.1 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.0% |
95.4%
12.4 pts worse
|
93.4%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.1% · Q2 87.2% · Q3 85.7% · Q4 81.2% · 4Q avg 83.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
96.9%
1.7 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.9% |
5.1%
4.8 pts worse
|
3.3%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 10.3% · Q3 11.4% · Q4 9.4% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.6%
2.3 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 3.3% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.5%
2.5 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 5.1% · Q3 8.8% · Q4 6.2% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
17.8%
2.2 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 12.8% · Q3 14.3% · Q4 15.6% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
25.1%
8.3 pts better
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.8% · Q3 21.7% · Q4 19.0% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.1% |
21.3%
2.8 pts worse
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 35.3% · Q3 29.5% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.1% |
21.6%
5.5 pts worse
|
14.9%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 38.9% · Q3 18.2% · Q4 15.6% · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
2.0%
0.5 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 7.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
3.3%
0.3 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.3% · Q3 2.9% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
25.8%
1 pts better
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 21.5% · Q3 23.5% · Q4 28.5% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.6%
2.1 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 3.8% · Q4 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.8% |
83.2%
19.4 pts worse
|
81.7%
17.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 63.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.7%
2.6 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-26
C · Minimal harm
2025-03-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-26
C · Minimal harm
2025-03-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-26
F · Potential for more than minimal harm
2023-12-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-06
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-18
C · Minimal harm
2023-12-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-22
C · Minimal harm
2023-12-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-22
D · Potential for more than minimal harm
2022-11-03
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-01
C · Minimal harm
2022-11-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-12-01
C · Minimal harm
2022-11-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-27
G · Actual harm
2025-04-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-02
G · Actual harm
2025-04-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-04-09
F761 · Pharmacy Service Deficiencies
Health
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 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-27
F · Potential for more than minimal harm
2025-03-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-12
F727 · Nursing and Physician Services Deficiencies
Health
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 2025-04-26
F · Potential for more than minimal harm
2025-03-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-27
F · Potential for more than minimal harm
2025-03-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-12
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-12
F837 · Administration Deficiencies
Health
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 2025-04-26
F · Potential for more than minimal harm
2025-03-12
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-03-12
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-03-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-12
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-12
F700 · Quality of Life and Care Deficiencies
Health
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 2025-05-08
E · Potential for more than minimal harm
2025-03-12
F761 · Pharmacy Service Deficiencies
Health
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 2025-04-26
E · Potential for more than minimal harm
2025-03-12
F909 · Environmental Deficiencies
Health
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.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-12
F758 · Pharmacy Service Deficiencies
Health
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 2025-04-26
E · Potential for more than minimal harm
2025-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-07
E · Potential for more than minimal harm
2023-12-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-20
D · Potential for more than minimal harm
2023-12-06
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-20
D · Potential for more than minimal harm
2023-12-06
F758 · Pharmacy Service Deficiencies
Health
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 2024-01-20
E · Potential for more than minimal harm
2022-11-03
F700 · Quality of Life and Care Deficiencies
Health
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 2022-12-23
Penalties and ownership
What sits behind the stars
$31,850
2025-03-12
Fine
Fine · fine $31,850
Fine
Ownership
Stroschein, Chad
Corporate Director · Individual
Stroschein, Chad
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Western Horizons Care Center
Hettinger, ND
1-star overall rating with 2-star inspections with abuse icon flag with $71,991 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Marian Manor Healthcare Center
Glen Ullin, ND
1-star overall rating with 1-star inspections with $22,835 in total fines with 6 recent health deficiencies
#3
Richardton Health Center Inc
Richardton, ND
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out