Cycle 1
Health 2025-04-25 · Fire 2025-04-25
12 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Mitchell, SD
Firesteel Healthcare Center
1-star overall rating with 1-star inspections with $110,798 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1120 East 7th Avenue, Mitchell, SD
(605) 996-6526
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1997-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
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
0.40
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
0.97
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.25
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,975
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.20
Baseline 16.72% · Performance 19.48% · Measure score 4.20 · Achievement 4.20 · Improvement 0
Healthcare-associated infections
0.63
Baseline 7.14% · Performance 7.65% · Measure score 0.63 · Achievement 0.63 · Improvement 0
Total nurse turnover
4.37
Baseline 51.52% · Performance 45.83% · Measure score 4.37 · Achievement 4.37 · Improvement 1.63
Adjusted total nurse staffing
2.08
Baseline 3.02 hours · Performance 3.67 hours · Measure score 2.08 · Achievement 2.08 · Improvement 1.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.65% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 8.7% · Lower 95% interval 7.02% |
| Discharge to community | 46.75% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 42.45% · Lower 95% interval 37.99% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 94.74% |
95.27%
0.5 pts worse
|
Numerator 90 · Denominator 95 |
| Falls with major injury | 2.11% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 95 |
| Discharge self-care score | 53.73% |
53.69%
About the same
|
Numerator 36 · Denominator 67 |
| Discharge mobility score | 53.73% |
50.94%
2.8 pts better
|
Numerator 36 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 2.11% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 95 · Adjusted rate 2.26% |
| Healthcare-associated infections requiring hospitalization | 7.65% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 7.25% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 3.91% |
8.2%
4.3 pts worse
|
Numerator 5 · Denominator 128 |
| Staff flu vaccination coverage | 82.67% |
42%
40.7 pts better
|
Numerator 124 · Denominator 150 |
| Discharge function score | 61.19% |
56.45%
4.7 pts better
|
Numerator 41 · Denominator 67 |
| Transfer of health information to provider | 41.18% |
95.95%
54.8 pts worse
|
Numerator 14 · Denominator 34 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 5.66% |
25.2%
19.5 pts worse
|
Numerator 3 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.9
1.2 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
95.4%
1 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 96.8% · Q3 98.0% · Q4 92.3% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
96.9%
0.2 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
5.1%
0.5 pts better
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.3% · Q3 4.1% · Q4 3.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.6%
4.3 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
5.5%
3.9 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 3.9% · Q4 1.2% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
17.8%
3.3 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 17.1% · Q3 12.0% · Q4 13.6% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
25.1%
1.1 pts better
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 21.1% · Q3 24.2% · Q4 28.6% · 4Q avg 24.0% · 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 | 17.8% |
21.3%
3.5 pts better
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 17.6% · Q3 20.0% · Q4 18.0% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
21.6%
4 pts better
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 11.1% · Q3 17.7% · Q4 21.0% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.0%
1.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
3.3%
1.2 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 4.4% · Q4 2.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
25.8%
1.1 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 26.6% · Q3 21.4% · Q4 30.5% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.6%
0.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.1% · Q3 1.8% · Q4 4.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.2% |
83.2%
9 pts worse
|
81.7%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 92.2% · Q3 67.2% · Q4 38.1% · 4Q avg 74.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
11.7%
0.8 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.9% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
1.7%
3.1 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.4% · Q3 0.0% · Q4 3.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.3% |
78.2%
2.9 pts worse
|
79.7%
4.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.7% |
21.5%
12.2 pts worse
|
23.9%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.7% · Observed 31.8% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-01-31 · Fire 2023-01-31
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-25
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-20
C · Minimal harm
2024-01-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-10
E · Potential for more than minimal harm
2023-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-09
Inspection history
Recent health citations
G · Actual harm
2025-12-18
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 2026-01-09
G · Actual harm
2025-12-18
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-12-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-22
H · Actual harm
2025-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
G · Actual harm
2025-04-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-25
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 2025-05-20
E · Potential for more than minimal harm
2025-04-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-25
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 2025-05-20
E · Potential for more than minimal harm
2025-04-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-25
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-20
D · 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 2025-01-21
D · Potential for more than minimal harm
2025-01-22
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 2025-02-14
E · Potential for more than minimal harm
2025-01-02
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-01-30
D · Potential for more than minimal harm
2025-01-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-18
D · Potential for more than minimal harm
2025-01-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-30
D · Potential for more than minimal harm
2025-01-02
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 2025-01-30
G · Actual harm
2024-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-27
G · Actual harm
2024-10-17
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 2024-10-04
G · Actual harm
2024-09-17
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 2024-10-12
G · Actual harm
2024-05-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-25
D · Potential for more than minimal harm
2024-04-23
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 2024-05-30
F · Potential for more than minimal harm
2024-01-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-10
E · Potential for more than minimal harm
2024-01-04
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 2024-02-10
D · Potential for more than minimal harm
2024-01-04
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-10
D · Potential for more than minimal harm
2023-01-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-01-31
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 2023-03-09
D · Potential for more than minimal harm
2023-01-31
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-09
Penalties and ownership
What sits behind the stars
$46,137
2025-04-25
Fine
Fine · fine $46,137
Fine
$34,320
2024-11-26
Fine
Fine · fine $34,320
Fine
$6,788
2024-10-17
Fine
Fine · fine $6,788
Fine
$15,041
2024-09-17
Fine
Fine · fine $15,041
Fine
$8,512
2024-05-30
Fine
Fine · fine $8,512
Fine
Ownership
Pacific Northwest SNF Operations Holdings (Sd) LLC
5% Or Greater Direct Ownership Interest · Organization
Bossman, Ann
Operational/Managerial Control · Individual
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Firesteel SNF Operations, LLC
Operational/Managerial Control · Organization
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Lowe, Leonor
Operational/Managerial Control · Individual
Mirkovic, Petar
Operational/Managerial Control · Individual
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Pacific Northwest SNF Operations Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Perlman, Harold
Operational/Managerial Control · Individual
Peterson, Scott
Operational/Managerial Control · Individual
South Dakota SNF Consulting LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Spielman, Shimon
Corporate Officer · Individual
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Yenowitz, Yitzchok
5% Or Greater Indirect Ownership Interest · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avera Brady Health And Rehab
Mitchell, SD
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Avera Bormann Manor
Parkston, SD
3-star overall rating with 3-star inspections with $34,749 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Prairie View Healthcare Center
Woonsocket, SD
2-star overall rating with 3-star inspections with $8,512 in total fines with 7 recent health deficiencies
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