Firesteel Healthcare Center
1120 East 7th Avenue, Mitchell, SD 57301
Firesteel Healthcare Center is a nursing home in Mitchell, South Dakota. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 1 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (605) 996-6526
- Last standard health inspection
- July 30, 2026 (3 months ago)
- Certified beds
- 125
- Residents per day, on average
- 104
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Firesteel SNF Operations, LLC
- Chain
- Evergreen Healthcare Group
- Takes part in
- Medicare and Medicaid
More health citations than the South Dakota average (39 vs 18).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
10 citations
Health inspection on July 30, 2026
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
30 of 96 South Dakota homes (31%) got a citation at the actual harm level in 2026.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 20, 2026.
CMS has cited this home for F0689 6 times since 2024.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on August 20, 2026.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 20, 2026.
CMS has cited this home for F0684 4 times since 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on August 20, 2026.
CMS has cited this home for F0812 3 times since 2024.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on August 20, 2026.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on August 20, 2026.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on August 20, 2026.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on August 20, 2026.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on August 20, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 20, 2026.
CMS has cited this home for F0880 3 times since 2024.
6 citations
Fire safety inspection on July 30, 2026
CMS lists this as a standard inspection.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on August 20, 2026.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on August 20, 2026.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on August 20, 2026.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 20, 2026.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on August 20, 2026.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 20, 2026.
CMS update of July 29, 2026
Fine
CMS changed the fine from December 18, 2025 from $65,400 to $42,510.
3 citations
Health inspection on May 28, 2026
CMS lists this as a complaint inspection.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on May 28, 2026.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 1, 2026.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 28, 2026.
CMS update of March 25, 2026
Ownership
CMS lists this home under a new chain.
Fine
CMS changed the fine from April 25, 2025 from $70,980 to $46,137.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Fine
CMS changed the fine from September 17, 2024 from $23,140 to $15,041.
Fine
CMS changed the fine from October 17, 2024 from $13,575 to $6,788.
Fine
CMS changed the fine from November 26, 2024 from $52,800 to $34,320.
3 citations
Health inspection on December 18, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
37 of 96 South Dakota homes (39%) got a citation at the actual harm level in 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 9, 2026.
Citation F0740. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on December 22, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on December 22, 2025.
CMS has cited this home for F0658 2 times since 2025.
Fine
December 18, 2025 (10 months ago)
CMS fine of $42,510 on December 18, 2025.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5.
Fine
CMS changed the fine from May 30, 2024 from $13,095 to $8,512.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
9 citations
Health inspection on April 25, 2025
CMS lists this as a standard inspection and a complaint inspection.
Severity H is the second-highest of CMS's four levels. It means a resident was harmed.
37 of 96 South Dakota homes (39%) got a citation at the actual harm level in 2025.
Citation F0880. Severity H: actual harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 20, 2025.
Citation F0925. Severity G: actual harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on May 20, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 20, 2025.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 20, 2025.
CMS has cited this home for F0584 2 times since 2024.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 20, 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 20, 2025.
Citation F0847. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
CMS lists it as corrected on May 20, 2025.
Citation F0867. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on May 20, 2025.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on May 20, 2025.
3 citations
Fire safety inspection on April 25, 2025
CMS lists this as a standard inspection.
Citation K0226. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have horizontal exits used in accordance with safety requirements.
CMS lists it as corrected on May 20, 2025.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 20, 2025.
Citation K0271. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on May 20, 2025.
Fine
April 25, 2025 (1 year ago)
CMS fine of $46,137 on April 25, 2025.
2 citations
Health inspection on January 22, 2025
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 21, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 14, 2025.
4 citations
Health inspection on January 2, 2025
CMS lists this as a complaint inspection.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 30, 2025.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on December 18, 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on January 30, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 30, 2025.
1 citation
Health inspection on November 26, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 27, 2024.
Fine
November 26, 2024 (1 year ago)
CMS fine of $34,320 on November 26, 2024.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
1 citation
Health inspection on October 17, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 4, 2024.
Fine
October 17, 2024 (2 years ago)
CMS fine of $6,788 on October 17, 2024.
CMS update of September 26, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
1 citation
Health inspection on September 17, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.
Citation F0725. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on October 12, 2024.
Fine
September 17, 2024 (2 years ago)
CMS fine of $15,041 on September 17, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
1 citation
Health inspection on May 30, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on January 25, 2024.
Fine
May 30, 2024 (2 years ago)
CMS fine of $8,512 on May 30, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
1 citation
Health inspection on April 23, 2024
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 30, 2024.
CMS update of February 29, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
3 citations
Health inspection on January 4, 2024
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 10, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 10, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 10, 2024.
1 citation
Fire safety inspection on January 4, 2024
CMS lists this as a standard inspection.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 10, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS (SD) LLC5% or greater direct ownership interest · 100% · since 08/31/2023
- COUVE FINANCIAL SERVICES LLCOperational/managerial control · not applicable · since 08/31/2023
- COUVE HEALTHCARE CONSULTING LLCOperational/managerial control · not applicable · since 08/31/2023
- FIRESTEEL SNF OPERATIONS, LLCOperational/managerial control · not applicable · since 08/31/2023
- PACIFIC NORTHWEST OPCO MANAGEMENT LLCOperational/managerial control · not applicable · since 08/31/2023
- SOUTH DAKOTA SNF CONSULTING LLCOperational/managerial control · not applicable · since 08/31/2023
- BOSSMAN, ANNOperational/managerial control · not applicable · since 08/31/2023
- LOWE, LEONOROperational/managerial control · not applicable · since 08/31/2023
- MIRKOVIC, PETAROperational/managerial control · not applicable · since 08/31/2023
- PETERSON, SCOTTOperational/managerial control · not applicable · since 08/31/2023
- SPIELMAN, SHIMONOperational/managerial control · not applicable · since 08/31/2023
- YENOWITZ, YITZCHOKOperational/managerial control · not applicable · since 08/31/2023
Questions
When was Firesteel Healthcare Center last inspected?
CMS lists July 30, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Firesteel Healthcare Center have?
CMS lists 39 health citations since January 4, 2024. CMS also calls these deficiencies.
Has Firesteel Healthcare Center been fined?
CMS lists 6 fines in the past three years, $153,308 in total.
What is the CMS star rating of Firesteel Healthcare Center?
Its CMS overall star rating is 1 of 5.
Is Firesteel Healthcare Center a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.