Firesteel Healthcare Center
1120 East 7th Avenue · Mitchell, SD · 57301 · 6059966526
125 certified beds For profit - Limited Liability company Chain: Evergreen Healthcare Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $167,686 in fines in the last 24 months.
- 8 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
4 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$167,686 in federal fines in the last 24 months
5 fines — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.56 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.46 | 0.55–0.75 |
| Weekend hours / resident-day | 3.06 | ≈ weekday level |
| Nursing turnover / year | 58% | median 45% |
| Fines (3-yr window) | 6 · $176,198 |
Inspection citations (30 in the current record)
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Actual harm · G December 18, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 9, 2026 · Quality of Life and Care
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Actual harm · G December 18, 2025 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected December 22, 2025 · Quality of Life and Care
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Potential for harm · D December 18, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 22, 2025 · Resident Assessment and Care Planning
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Actual harm · G April 25, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected May 20, 2025 · Environmental
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Actual harm · H April 25, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 20, 2025 · Infection Control
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Potential for harm · D April 25, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected May 20, 2025 · Resident Rights
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Potential for harm · E April 25, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 20, 2025 · Resident Assessment and Care Planning
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Potential for harm · F April 25, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 20, 2025 · Nutrition and Dietary
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Potential for harm · E April 25, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected May 20, 2025 · Administration
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Potential for harm · E April 25, 2025 · found via complaint
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 May 20, 2025 · Resident Rights
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Potential for harm · E April 25, 2025 · found via complaint
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 May 20, 2025 · Resident Rights
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Potential for harm · E April 25, 2025 · found via complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected May 20, 2025 · Administration
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Potential for harm · D January 22, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 21, 2025 · Quality of Life and Care
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Potential for harm · D January 22, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 14, 2025 · Quality of Life and Care
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Potential for harm · D January 2, 2025 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected December 18, 2024 · Resident Rights
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Potential for harm · D January 2, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · D January 2, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 30, 2025 · Quality of Life and Care
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Potential for harm · E January 2, 2025 · found via complaint
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 January 30, 2025 · Nutrition and Dietary
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Actual harm · G November 26, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 27, 2024 · Quality of Life and Care
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Actual harm · G October 17, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 4, 2024 · Quality of Life and Care
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Actual harm · G September 17, 2024 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected October 12, 2024 · Nursing and Physician Services
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Actual harm · G May 30, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected January 25, 2024 · Pharmacy Service
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Potential for harm · D April 23, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 30, 2024 · Quality of Life and Care
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Potential for harm · D January 4, 2024
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 February 10, 2024 · Resident Rights
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Potential for harm · E January 4, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 10, 2024 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 18, 2025 | Fine | $65,400 |
| April 25, 2025 | Fine | $46,137 |
| November 26, 2024 | Fine | $34,320 |
| October 17, 2024 | Fine | $6,788 |
| September 17, 2024 | Fine | $15,041 |
| May 30, 2024 | Fine | $8,512 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435109 · certified since November 1, 1997. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.