Firesteel Healthcare Center
Mitchell, South Dakota · CCN 435109
29 surveys since 2010, 19 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 136
- Surveys
- 29
- Harm or worse
- 19
- Immediate jeopardy
- 6
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 125
- Ownership
- For profit - Limited Liability company
- Chain
- EVERGREEN HEALTHCARE GROUP
- County
- Davison · rural
- Medicare-certified since
- 1997
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 2
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 31 for-profit facilities in South Dakota.
Last survey on record
Jul 30, 2026
102 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.47 | 3.47 |
| Registered-nurse hours per resident day | 0.51 | — |
| Annual nurse turnover | 55.0% | 55.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $153,308 across 6 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G818.6% | H12.3% | I— |
| No harm, potential for more than minimal | D1944.2% | E1330.2% | F24.7% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6896×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6844×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F8804×
Provide and implement an infection prevention and control program.
- F6583×
Ensure services provided by the nursing facility meet professional standards of quality.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
In the surveyor’s words
From the most serious findings on record at Firesteel Healthcare Center, in the surveyor’s own words.
- Immediate jeopardy, widespreadF880Jan 21, 2021
Based on observation, interview, policy review, record review, and reference source review, the provider failed to implement proper infection control practices for the coronavirus (COVID-19) pandemic with the potential for exposing residents and staff to serious harm including death. On 1/20/21 at 3:45 p.m. an immediate jeopardy was identified when the provider failed to ensure: A. Ensure N95 masks worn into quarantine rooms were discarded or changed upon leaving (widespread). B. Disinfect face shields after contact with quarantined residents (widespread). C. Ensure one of twenty-three residents (1) remained quarantined while in quarantine status. D. Ensure staff caring for quarantined residents were aware of how to properly remove personal protective equipment (PPE) (widespread). E. […]
- Immediate jeopardy, patternF686Jan 21, 2021
Based on observation, interview, record review, policy review, South Dakota Department of Health (SD DOH) on-line incident report, and job description review, the provider failed to follow their Skin Integrity policy for: *Accuracy of weekly skin assessments and/or wound documentation for eighteen of twenty-three sampled residents (1, 2, 3, 4, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 21, 22, 24, and 25). *physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Notification to physician, resident and/or family representative of skin and wound issues in a timely manner for seven of twenty-three sampled residents (2, 3, 4, 13, 14, 15, and 23). *A turning and repositioning program for ten of twenty-three sampled residents (2, 3, 4, 10, 11, 15, 22, 23, 24, and 25) to off load pressure areas. […]
- Immediate jeopardy, isolatedF678Jan 21, 2021
Based on interviews, closed record review, policy review, and the unexpected death report submitted to the South Dakota Department of Health (SD DOH), revealed the provider failed to ensure one of one closed sampled resident record (5) who was a full code, with no pulse or respirations received emergency services for cardiopulmonary resuscitation (CPR). Surveyor: : All residents who are full code status have the potential to be affected by this deficient practice. NOTICE: Verbal notice of immediate jeopardy and the template was given on [DATE] at 6:00 p.m. An immediate jeopardy was identified when the facility failed to start CPR immediately for one of one resident who was a full code status. […]
- Immediate jeopardy, isolatedF684Jan 21, 2021
Based on observation, interview, record review, closed record review, policy review, and South Dakota Department of Health (SD DOH) online report, the provider failed to ensure residents received treatment and care in accordance with professional standards of practice for: A. Ensuring monitoring and dosing for one of one newly admitted sampled (6) resident receiving monitoring of anti-coagulant therapy for signs and symptoms of bleeding. B. Resident call lights were answered in a timely manner for two of two sampled residents (7 and 8). C. Resident's received a bath every seven days for seven of seven sampled residents (11, 12, 13, 14, 15, 16, and 22). D. Facility having enough walkie talkies for staff to be able to meet each resident needs (non-IJ finding). E. […]
- Immediate jeopardy, isolatedF697Jan 21, 2021
Based on interview, record review, policy review, and the South Dakota Department of Health (SD DOH) online report review, revealed the provider failed to ensure one of three closed record sampled residents (19) and one of one sampled resident (7) received pain management for ensuring a: *Hospice resident's pain was managed, and the provider and/or hospice agency was notified. *Resident who was receiving pain medication received her medication timely. Surveyor These failures have a potential to expose all residents not receiving effective pain management to have their quality of life to be affected. NOTICE: Verbal notice of immediate jeopardy and the template was given on 2/19/21 at 6:00 p.m. […]
Read 34 findings in full →The most serious and the most recent: 34 of 136 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 30, 2026Standard and complaint10 findings · 1 harm
- May 28, 2026Complaint3 findings
- Dec 18, 2025Complaint3 findings · 2 harm
- Apr 25, 2025Standard and complaint9 findings · 2 harm
- Jan 22, 2025Complaint2 findings
- Jan 2, 2025Complaint4 findings
- Nov 26, 2024Complaint1 finding · 1 harm
- Oct 17, 2024Complaint1 finding · 1 harm
Show the 21 earlier surveys
- Sep 17, 2024Complaint1 finding · 1 harm
- May 30, 2024Complaint1 finding · 1 harm
- Apr 23, 2024Complaint1 finding
- Jan 4, 2024Standard3 findings
- Jan 31, 2023Standard4 findings
- Feb 10, 2022Complaint3 findings
- Sep 10, 2021Standard9 findings
- Jan 21, 2021Complaint7 findings · 5 harm
- May 30, 2019Standard8 findings
- Feb 7, 2018Standard2 findings
- May 2, 2017Complaint2 findings
- Nov 9, 2016Standard11 findings
- Jan 7, 2016Standard6 findings
- Apr 2, 2015Standard6 findings
- Dec 16, 2014Complaint4 findings · 2 harm
- May 7, 2014Standard12 findings
- Feb 27, 2013—5 findings
- Mar 14, 2012—4 findings
- Jun 22, 2011—4 findings · 2 harm
- May 11, 2011—9 findings · 1 harm
- Oct 6, 2010—1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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