Home / South Dakota / Lemmon
405 6th Avenue West, Lemmon, SD 57638 · Perkins County · (605) 374-3871
38 certified beds, about 35 residents a day · Non profit - Corporation · Medicare and Medicaid since 1995
CMS Care Compare ratings, data as of September 1, 2026 · CCN 435090 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 7, 2026, inspectors cited 4 health deficiencies (the South Dakota average is 6.7, the national average 9.2).
Of 37 health citations since December 2023, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $20,703 in the last three years; the largest was $20,703, and the latest is dated March 12, 2025.
Nurses and nurse aides worked 2.90 hours per resident per day, against 3.79 across South Dakota and 3.86 nationally. Registered nurses accounted for 0.76 of those hours.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 37 health citations on file.
Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices regarding: *Hand hygiene (handwashing or the use of an alcohol-based hand sanitizer) and glove use by two of two cooks (J and K) who did not wash their hands as required and wore soiled gloves to handle ready-to-eat foods, one of one restorative therapy (RT) (D) who did not wash her hands between feeding a resident and eating her own meal, and one of one certified nursing assistant (CNA)/certified medication aide (CMA) (E) who did not remove her soiled gloves before handling food items during two of two meal services. *The disposal of garbage away from a portable food serving station during one of two observed meal services.
Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure a homelike environment and staff assistance was provided in one of one dining room during two of two observed mealtimes.
Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure a self-administration of medication assessment was completed for one of one sampled resident (10) who was allowed to keep her bedtime medications in a cup on her nightstand without supervision.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (31) who was left outside of his room unsupervised by one of one certified nurse aide (CNA) (M) after his room was cleaned and the floor was wet, which placed the resident at risk for falling and sustaining an injury.
Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one cognitively impaired sampled resident (3), identified as being at risk for elopement, who eloped (left the facility without staff knowledge) and was outside of the building for an unknown amount of time after she entered the doorlock's key pad code and exited the building. Failure to adequately supervise and monitor the resident's location and to provide environmental controls (doorlock keypad code unknown to the resident) may have contributed to her elopement and placed the resident at risk for an accident and/or injury while she was out of the building and unsupervised.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure medications were securely stored and inaccessible to unauthorized individuals including: *Two of two unauthorized individuals (administrator A and maintenance director M) who had access to one of one medication room where controlled medications (medications at risk for abuse and addiction) were stored in an unsecured manner. *One of one certified nursing assistant (CNA)/certified medication aide (CMA) N who had not securely stored the keys to one of two medication cart and a drawer where controlled medications were stored for two of two observations.
Inspectors wroteBased on review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), observation, record review, interview, and policy review, the provider failed to ensure a thorough investigation was completed and reported to the SD DOH regarding a facial bruise of unknown origin for one of one sampled resident (1).
Inspectors wroteBased on review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), record review, observation, and interview, the provider failed to follow professional standards to ensure a resident's physician ordered: *Fluid restriction was implemented effectively and accurately documented for one of one sampled resident (1). *Basic metabolic panel (BMP) laboratory (lab) test (a common blood test that measures levels of key electrolytes including sodium, glucose, and kidney function indicators) was not completed for one of one sampled resident (1) who had been diagnosed with a low sodium level (hyponatremia).
Inspectors wroteBased 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).
Inspectors wroteBased 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. Review of the RN staff timecards for fiscal year 2024 revealed: *The DON timecard for 2/3/24 was not produced by the provider to verify hours worked. *RN coverage for eight consecutive hours could not be verified for 1/13/24, 1/14/24, and 2/17/24. 3. [...]
Inspectors wroteBased 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.
Inspectors wroteBased on observation, record review, interview and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential theft) to ensure accurate and complete documentation for those medications related to their receipt, counts, administration details including the dates given and the resident names, and destruction process.
Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to follow standard food safety practices to ensure: *The mechanical dishwashers, refrigerator, and freezer temperatures were monitored and logged according to their policy. *Single-use food containers were not used to store leftover food. *Clean dishes were not stored on frayed cloth towels.
Inspectors wroteBased on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered by administrator A, director of nursing (DON) B, and assistant director of nursing (ADON) G, in a manner that ensured quality of life and overall well-being for all 39 residents in the facility.
Inspectors wroteBased on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all 39 residents in the facility.
Inspectors wroteBased on record review, interview, and Arbitration Agreement review, the provider failed to ensure seven of thirteen sampled residents (13, 21, 23, 24, 25, 36, and 142) and three of three recently admitted residents (38, 39, and 142) who had entered into an Arbitration Agreement upon admission to the facility: *Were not required to sign a binding arbitration agreement as a condition of admission to receive care at the facility. *Were explained the arbitration agreement in a form and manner including a language that the resident or his/her representative understood. *Were explicitly granted the right to rescind the agreement within 30 calendar day of signing it.
Inspectors wroteBased on interview and Arbitration Agreement review, the provider failed to ensure the provider's Arbitration Agreement: *Included the arbitration organization's name and how to contact that organization. *Provided for the selection of a neutral arbitrator agreed upon by both parties. *Provided for a location that was convenient for both parties for an arbitration dispute.
Inspectors wroteBased on Payroll Based Journal (PBJ) record review, employee timecard review, and interview, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters reviewed Quarter 2, 2024 (January 1 through March 31, 2024); Quarter 3, 2024 (April 1 through June 30, 2024)2024); and Quarter 4, 2024 (July 1 through September 30, 2024).
Inspectors wroteBased on interview, and quality assurance and performance improvement (QAPI) plan policy review, the provider failed to ensure they had identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, or monitored regarding nurse staffing, siderails, medication administration and storage, baseline care plans, and arbitration agreements.
Inspectors wroteBased on record review and interview, the provider failed to ensure the proper Medicare Notices were completed accurately for: *Two of two sampled residents (10 and 33) who had remained in the facility following their discharge from Medicare part A skilled services. *One of one sampled resident (41) who had discharged to home following their discharge from Medicare part A skilled services.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled resident (9 and 21) privacy had been maintained related to audio or video monitoring devices. The provider had not followed their policy for video monitoring related to: *Ensuring a cognitively intact resident had consented and been aware of the monitoring device in his room. *Staff training and awareness with the devices including which residents had them, when to turn off or block the device to ensure the residents' privacy, the process for consents by the residents and staff, and ensuring a sign was posted to notify others of the video monitoring device.
Inspectors wrote2. Observation and interview on 3/10/25 at 8:51 a.m. of resident 142 revealed she: *Was seated in a wheelchair by the bathing room. *Stated she was recently admitted for occupational therapy and physical therapy. *Planned to return to her home within the next 30 days. Review of resident 142's EMR revealed: *She was admitted on [DATE]. *Her 3/4/25 BIMS assessment score was a 14, which indicated her cognition was intact. *Her diagnoses included: muscle weakness, Erythema Intertrigo (redness, inflammation, and irritation in the skin folds), lumbar radiculopathy (compressed or irritated nerves in the back that may cause pain and other symptoms), and retention of urine. *Her 3/4/25 baseline care plan included focus areas of: -She did not have a POA (financial and care). [...]
Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to follow professional standards of practice related to: *Physician notification of and implementation of appropriate interventions for one of one sampled resident's (36) significant weight loss as directed in their policy. *Identification and implementation of interventions for one of one sampled resident (5) with low blood sugars. *Holding the administration of insulin for one of one sampled resident (5) with low blood sugars without a physician's order.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to assess two of two (24 and 36) sampled residents for their need for trauma-informed care. 1. Observation and interview on 3/9/25 at 3:10 p.m. with resident 24 revealed: *Her room had piles of clothing, books, and papers. *She believed someone had taken some of her belongings. *She believed her daughters had been molested by her husband. Review of resident 24's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 1/27/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her diagnoses included anxiety and major depressive disorder. -A copy of resident 24's trauma-informed care assessment was requested from the provider on 3/11/25 at 4:10 p.m. but was not provided for review by the end of the survey. [...]
Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure residents who used bed rails/assist bars had: *A signed consent for their use for two of twelve sampled residents (23 and 25). *The medical symptoms for use documented on the Side Rail Assessments for five of twelve sampled residents (6, 9,13, 21, and 36). *Received education on the risks of use versus benefits of use of side rails/assist bars for one of twelve sampled residents (9). *Other attempted interventions documented on the Side Rail Assessment for one of twelve sampled residents (23).
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to: *Ensure medications were labeled properly for four of four random residents (3, 5, 20, and 32) related to having the pharmacy label remain with the medication and to follow the manufacturers' instructions for use-by dates. *Ensure proper labeling and storage of medication for one of one resident (29) with a medicated ointment stored unsecured in her room.
Inspectors wroteBased on observation, interview, and policy review, the provider failed to assess side rails on 13 of 13 sampled residents' beds (2, 3, 5, 6, 9, 13, 16, 21, 23, 24, 25, 36, and 142) routinely as a part of a safety and preventative maintenance program to ensure those side rails were in good working order and safe from possible resident entrapment or injury.
Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure a thorough investigation was completed regarding an allegation of abuse for one of one sampled resident (5).
Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure documentation related to a gradual dose reduction (GDR) had occurred to support the rationale for not completing a GDR for one of one sampled resident (5) who received psychotropic medications (any medication that affects brain activities associated with mental processes and behaviors).
Inspectors wrote2. Review of SD DOH complaint report submitted on 1/15/25 at 4:53 p.m. revealed: *The complainant wished to remain anonymous. *The complainant reported concerns with the accuracy of resident assessments and timeliness of the documentation of resident assessments at the facility. 3. A review of resident 2's electronic medical record (EMR) revealed: *Her diagnoses included secondary hypertension (high blood pressure from an underlying medical condition), hyperlipidemia (high cholesterol), chronic obstructive pulmonary disease (COPD), anemia, peripheral vascular disease (progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel), and essential hypertension (the most common type of high blood pressure). *Previous vital signs were documented instead of having checked and documented her current vital signs each day. From 10/4/24 to 11/12/24, her: [...]
Inspectors wroteBased on observation, interview, record review, and policy review, the provided failed to ensure the following: *Post-fall monitoring was completed and documented in a timely manner for one of one sampled resident (26) who had fallen. *A physician's order was followed and suprapubic catheter cleaning and care at the insertion site was completed and documented for one of one sampled resident (11). *The use of a chair alarm was monitored and documented for one of one sampled resident (14 ) who required a chair alarm.
Inspectors wroteBased on record review, interview and policy review, the provider failed to have an acknowledged and signed code status that was easily accessible for three of three sampled residents (186, 32, and 33).
Inspectors wroteBased on observation, interview, record review, job description review, and policy review, the provider failed to follow a process to thoroughly assess, implement, monitor, and revise interventions for one of one sampled resident (26) who was at nutritional risk.
Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the bed hold notice was given upon the transfer on three separate dates for one of one sampled resident (10) to the hospital.
Inspectors wroteBased on review of the Consultant Pharmacist Review reports for 2023, record review, and interview, the provider failed to ensure a physician's order included a specific duration of time for an as needed (PRN) psychotropic medication for one of one sampled resident (1) who received a PRN psychotropic medication.
14 fire safety citations on file: 2 on May 7, 2026, 5 on March 12, 2025, 7 on December 6, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| March 12, 2025 | Fine | $20,703 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | South Dakota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 2.90 | 3.79 | 3.86 |
| Registered nurses | 0.76 | 0.80 | 0.69 |
| All nursing staff on weekends | 2.51 | 3.26 | 3.42 |
| Nurse aides | 1.95 | ||
| Licensed practical nurses | 0.19 | ||
| Nursing staff turnover (share who left in a year) | not reported | 48.2% | 45.8% |
| Registered nurse turnover | not reported | 34.7% | 42.9% |
| Administrators who left | not reported |
CMS expects 2.89 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.05 on weekdays and 2.51 on weekends, 18% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 24.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.22 in April to June 2025 to 2.90 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 2.90 | 0.76 | 3.05 | 2.51 | 24.9% | 2 of 90 | 35 |
| Oct to Dec 2025 | 3.23 | 0.92 | 3.39 | 2.83 | 45.0% | 0 of 92 | 30 |
| Jul to Sep 2025 | 3.02 | 0.86 | 3.20 | 2.57 | 60.6% | 0 of 92 | 32 |
| Apr to Jun 2025 | 3.22 | 0.69 | 3.47 | 2.58 | 49.5% | 3 of 91 | 34 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| South Dakota, Jan to Mar 2026 | 3.76 | 0.79 | 3.97 | 3.25 | 9.1% | 1.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| South Dakota, all employers | |||
| CNAs (nursing assistants) | $18.65 | $17.71 to $21.12 | 6,860 |
| LPNs and LVNs | $25.36 | $23.88 to $29.47 | 2,050 |
| Registered nurses | $37.53 | $31.29 to $40.52 | 14,710 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | South Dakota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 21.6 | 21.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 3.3 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 4.8 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 8.7 | 5.5 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 17.4 | 19.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.4 | 4.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 19.3 | 24.6 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 1.8 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Five Counties Nursing Home's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · South Dakota: 7 better, 10 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 22 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · South Dakota: 0 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 29 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · South Dakota: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 16 eligible stays.
47.6% this home
Median of homes: South Dakota52.7% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 21 residents counted.
0.0% this home
Median of homes: South Dakota1.1% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 21 residents counted.
0.0% this home
Median of homes: South Dakota2.5% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 21 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: South Dakota100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 7 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: LEMMON AREA MEDICAL ASSOCIATION.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Stroschein, Chad | W-2 managing employee | Individual | 11/19/2018 | |
| Stroschein, Chad | Corporate director | Individual | 11/19/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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