Firesteel Healthcare Center
1120 East 7th Avenue, Mitchell, SD 57301 · Davison County · 125 certified beds · avg 107 residents/day · certified since Nov 1, 1997
Part of chain: EVERGREEN HEALTHCARE GROUP (44 facilities, chain avg rating 2.5★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 18, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 18, 2025 · F-0740 · triggered by a complaint
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Apr 25, 2025 · F-0880 · triggered by a complaint
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: May 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 25, 2025 · F-0925
The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Why it matters: Pests spread germs, contaminate food, and signal broader problems with cleanliness.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 26, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 17, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 4, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Sep 17, 2024 · F-0725 · triggered by a complaint
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 12, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 30, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 25, 2024 (Past Non-Compliance)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 28, 2026 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 28, 2026 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 28, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 18, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 18, 2025 | ▲ G · Actual harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Dec 18, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Apr 25, 2025 | ▲ H · Actual harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Apr 25, 2025 | ▲ G · Actual harm, one-off | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Apr 25, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jan 22, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 22, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 2, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Jan 2, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jan 2, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jan 2, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 26, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 17, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 17, 2024 | ▲ G · Actual harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| May 30, 2024 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 23, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 4, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 4, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 4, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jan 31, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jan 31, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 31, 2023 | D · Potential for harm, one-off | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Jan 31, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | D |
| 2024 | 8 | 4 | G ▲ |
| 2025 | 18 | 4 | H ▲ |
| 2026 | 3 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
6 fines totaling $153,308.
| Date | Type | Amount / length |
|---|---|---|
| Dec 18, 2025 | Fine | $42,510 |
| Apr 25, 2025 | Fine | $46,137 |
| Nov 26, 2024 | Fine | $34,320 |
| Oct 17, 2024 | Fine | $6,788 |
| Sep 17, 2024 | Fine | $15,041 |
| May 30, 2024 | Fine | $8,512 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.74 | 4.32 | 3.95 | bottom 36% in South Dakota; bottom 49% in the U.S. |
| Registered Nurse hours | 0.55 | 0.91 | 0.69 | bottom 6% in South Dakota; bottom 45% in the U.S. |
| Weekend total nurse staffing | 3.17 | 3.71 | 3.50 | bottom 35% in South Dakota; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.17 | 0.51 | 0.48 | bottom 1% in South Dakota; bottom 7% in the U.S. |
| Total nursing staff turnover (%) | 55.0 | 48.2 | 45.8 | bottom 29% in South Dakota; bottom 25% in the U.S. |
| RN turnover (%) | 46.2 | 34.7 | 42.9 | bottom 26% in South Dakota; bottom 42% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.47, RN 0.51, weekend 2.94. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Pacific Northwest SNF Operations Holdings (SD) LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/31/2023 |
| Bossman, Ann | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Bossman, Ann | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| CH Pacific Northwest Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Couve Financial Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Couve Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/07/2025 |
| Couve Healthcare Consulting LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Couve Healthcare Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/12/2025 |
| Firesteel SNF Operations, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Firesteel SNF Operations, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/31/2025 |
| Firesteel SNF Realty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/13/2025 |
| Herzka, Yisroel | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Lowe, Leonor | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/31/2023 |
| Lowe, Leonor | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Lowe, Leonor | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Mirkovic, Petar | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Mirkovic, Petar | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Pacific Northwest Opco Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Pacific Northwest Opco Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/07/2025 |
| Peterson, Scott | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What mental health services do you provide on-site, and who delivers them?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avera Brady Health and Rehab | 2.0 mi | Mitchell, SD | ★★★★★ | 5/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435109.