Federal inspection record · CMS data as of October 1, 2026
Firesteel Healthcare Center
1120 East 7th Avenue, Mitchell, SD · (605) 996-6526
- Special Focus Facility
- Certified beds
- 125
- Residents per day
- 104
- Ownership
- For-Profit
- Chain
- Evergreen Healthcare Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- November 1, 1997
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in South Dakota.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change (already 1)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among South Dakota homes
Firesteel Healthcare Center carries 158.75 inspection points. That is fewer than 4% of South Dakota's 94 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in South Dakota: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–14 pts
- 4★ 14–31.5 pts
- 3★ 31.5–55 pts
- 2★ 55–95.25 pts
- 1★ over 95.25 pts
Bars show every rated home in South Dakota by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
39 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (9)
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G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
-
H
Provide and implement an infection prevention and control program.
-
G
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
-
G
Ensure that residents are free from significant medication errors.
Everything else, by area of care
Resident Rights7E
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- E
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.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Keep residents' personal and medical records private and confidential.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Quality of Life and Care7E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nutrition and Dietary4F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning4E
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Infection Control3F
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
Administration2E
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Nursing and Physician Services1D
- D
Post nurse staffing information every day.
Freedom from Abuse, Neglect, and Exploitation1E
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Pharmacy Service1D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspection history
2026-07-30
16 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2025-04-25
17 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2024-01-04
6 health deficiencies · 1 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
4
Nursing time per resident, per day
Each resident here gets about 3 h 32 min of nursing staff time a day, 35 min of it from a registered nurse.
This home
3 h 32 min
South Dakota average
3 h 51 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 63% of nursing staff and 50% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$153,308 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-12-18 | Fine | $42,510 |
| 2025-04-25 | Fine | $46,137 |
| 2024-11-26 | Fine | $34,320 |
| 2024-10-17 | Fine | $6,788 |
| 2024-09-17 | Fine | $15,041 |
| 2024-05-30 | Fine | $8,512 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.5 pts worse | 2.0 | 1.5 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.8 pts worse | 2.5 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine17.3 pts worse | 77.6% | 94.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.1 pts better | 97.3% | 97.2% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.1 pts better | 4.4% | 5.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms5.4 pts better | 0.5% | 5.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.4 pts better | 2.3% | 5.7% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication4.2 pts better | 13.5% | 17.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.3 pts worse | 25.1% | 24.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.7 pts better | 17.6% | 18.3% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased1.6 pts better | 19.9% | 21.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.5 pts better | 0.4% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.7 pts better | 2.2% | 2.9% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.8 pts worse | 25.3% | 24.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.5 pts better | 3.0% | 4.5% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine52 pts worse | 31.9% | 83.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.7 pts worse | 15.0% | 13.3% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.8 pts worse | 4.0% | 2.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine42.8 pts worse | 32.7% | 75.5% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission5 pts worse | 25.0% | 20.0% | 23.4% |
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Who owns and runs it
30 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Pacific Northwest SNF Operations Holdings (Sd) LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 6 facilities |
| Bossman, Ann | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Bossman, Ann | Adp Of The SNF · Individual | 0% | 1 facilities |
| Ch Pacific Northwest Holdings LLC | Adp Of The SNF · Organization | 0% | 22 facilities |
| Couve Financial Services LLC | Operational/Managerial Control · Organization | 0% | 41 facilities |
| Couve Financial Services LLC | Adp Of The SNF · Organization | 0% | 41 facilities |
| Couve Healthcare Consulting LLC | Operational/Managerial Control · Organization | 0% | 50 facilities |
| Couve Healthcare Consulting LLC | Adp Of The SNF · Organization | 0% | 50 facilities |
| Firesteel SNF Operations, LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Firesteel SNF Operations, LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Firesteel SNF Realty LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Herzka, Yisroel | Adp Of The SNF · Individual | 0% | 75 facilities |
| Lowe, Leonor | Managing Control - Governing Body · Individual | 0% | 6 facilities |
| Lowe, Leonor | Operational/Managerial Control · Individual | 0% | 6 facilities |
| Lowe, Leonor | Adp Of The SNF · Individual | 0% | 6 facilities |
| Mirkovic, Petar | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Mirkovic, Petar | Adp Of The SNF · Individual | 0% | 1 facilities |
| Pacific Northwest Opco Management LLC | Operational/Managerial Control · Organization | 0% | 29 facilities |
| Pacific Northwest Opco Management LLC | Adp Of The SNF · Organization | 0% | 29 facilities |
| Peterson, Scott | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Peterson, Scott | Adp Of The SNF · Individual | 0% | 2 facilities |
| South Dakota SNF Consulting LLC | Operational/Managerial Control · Organization | 0% | 6 facilities |
| South Dakota SNF Consulting LLC | Adp Of The SNF · Organization | 0% | 6 facilities |
| Spielman, Shimon | Corporate Officer · Individual | 0% | 48 facilities |
| Spielman, Shimon | Operational/Managerial Control · Individual | 0% | 48 facilities |
| Spielman, Shimon | Adp Of The SNF · Individual | 0% | 48 facilities |
| Witzcorp Global LLC | Adp Of The SNF · Organization | 0% | 21 facilities |
| Yenowitz, Yitzchok | Corporate Officer · Individual | 0% | 50 facilities |
| Yenowitz, Yitzchok | Operational/Managerial Control · Individual | 0% | 50 facilities |
| Yenowitz, Yitzchok | Adp Of The SNF · Individual | 0% | 50 facilities |
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Fire safety
10 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4E
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
Egress3E
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Have horizontal exits used in accordance with safety requirements.
- D
Have exits that are accessible at all times.
Miscellaneous2D
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- C
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems1E
- E
Ensure proper usage of power strips and extension cords.
·
Other homes nearby
-
Avera Brady Health And Rehab
Mitchell, SD · Avera Health
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 35 min
- Fines
- $0
-
Avera Bormann Manor
Parkston, SD
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 42 min
- Fines
- $47,187
-
Prairie View Healthcare Center
Woonsocket, SD · Evergreen Healthcare Group
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 24 min
- Fines
- $8,512