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Part of chain: EVERGREEN HEALTHCARE GROUP (44 facilities, chain avg rating 2.5★)
1/5
Health inspection rating (on-site)
inspected Apr 25, 2025
8
Serious findings on record
most recent Dec 18, 2025
$153,308
Fines, last 3 years
3.74
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
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 quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jan 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Dec 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, pattern · 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): Actual harm was cited, below immediate jeopardy. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 20, 2025 (Deficient, Provider has date of correction)
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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Dec 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Oct 4, 2024 (Past Non-Compliance)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Oct 12, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jan 25, 2024 (Past Non-Compliance)
Inspection findings in the public record
Showing the latest 3 of 33 inspection findings. Open the full record below to read every finding.
E · Potential for more than minimal harm, pattern
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 complaintF-0609
E · Potential for more than minimal harm, pattern
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 complaintF-0684
D · Potential for more than minimal harm, isolated
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 complaintF-0755
View all 33 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
Date
Severity
What the facility was cited for
May 28, 2026
E · Potential for more than minimal harm, pattern
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 · F-0609
May 28, 2026
E · Potential for more than minimal harm, pattern
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 · F-0684
May 28, 2026
D · Potential for more than minimal harm, isolated
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 · F-0755
Dec 18, 2025
▲ G · Actual harm, isolated
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 · F-0689
Dec 18, 2025
▲ G · Actual harm, isolated
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 · F-0740
Dec 18, 2025
D · Potential for more than minimal harm, isolated
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 · F-0658
Apr 25, 2025
▲ H · Actual harm, pattern
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 · F-0880
Apr 25, 2025
▲ G · Actual harm, isolated
The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · F-0925
Apr 25, 2025
F · Potential for more than minimal harm, widespread
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. · F-0812
Apr 25, 2025
E · Potential for more than minimal harm, pattern
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Apr 25, 2025
E · Potential for more than minimal harm, pattern
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 · F-0625
Apr 25, 2025
E · Potential for more than minimal harm, pattern
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. · F-0656
Apr 25, 2025
E · Potential for more than minimal harm, pattern
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. · F-0847
Apr 25, 2025
E · Potential for more than minimal harm, pattern
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint · F-0867
Apr 25, 2025
D · Potential for more than minimal harm, isolated
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. · F-0554
Jan 22, 2025
D · Potential for more than minimal harm, isolated
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 · F-0684
Jan 22, 2025
D · Potential for more than minimal harm, isolated
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 · F-0689
Jan 2, 2025
E · Potential for more than minimal harm, pattern
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 · F-0803
Jan 2, 2025
D · Potential for more than minimal harm, isolated
The facility did not keep residents' personal and medical information private and confidential. · from a complaint · F-0583
Jan 2, 2025
D · Potential for more than minimal harm, isolated
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 · F-0658
Jan 2, 2025
D · Potential for more than minimal harm, isolated
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 · F-0689
Nov 26, 2024
▲ G · Actual harm, isolated
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 · F-0684
Oct 17, 2024
▲ G · Actual harm, isolated
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 · F-0689
Sep 17, 2024
▲ G · Actual harm, isolated
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 · F-0725
May 30, 2024
▲ G · Actual harm, isolated
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 · F-0760
Apr 23, 2024
D · Potential for more than minimal harm, isolated
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 · F-0689
Jan 4, 2024
F · Potential for more than minimal harm, widespread
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. · F-0880
Jan 4, 2024
E · Potential for more than minimal harm, pattern
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. · F-0812
Jan 4, 2024
D · Potential for more than minimal harm, isolated
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
Jan 31, 2023
D · Potential for more than minimal harm, isolated
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Jan 31, 2023
D · Potential for more than minimal harm, isolated
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. · F-0758
Jan 31, 2023
D · Potential for more than minimal harm, isolated
The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · F-0801
Jan 31, 2023
D · Potential for more than minimal harm, isolated
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. · F-0880
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 9).
Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations:
4
Serious citations (G–L):
0
2024
All citations:
8
Serious citations (G–L):
4
2025
All citations:
18
Serious citations (G–L):
4
2026
All citations:
3
Serious citations (G–L):
0
All bars start at zero. Exact values and supporting details remain below.
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.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
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)
Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilitySouth Dakota averageU.S. average
Total nurse staffing (hours per resident per day)
This facility:
3.74
South Dakota average:
4.32
U.S. average:
3.95
Registered Nurse hours
This facility:
0.55
South Dakota average:
0.91
U.S. average:
0.69
Weekend total nurse staffing
This facility:
3.17
South Dakota average:
3.71
U.S. average:
3.50
All bars start at zero. Exact values and supporting details remain below.
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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.47 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
No verified facility-specific private-pay price is available in our data for Firesteel Healthcare Center. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
Request the room type, effective date and itemized daily rate in writing.
Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Showing 20 of 30 parties CMS has on file for this facility; 10 are not displayed. The full list is in the CMS Ownership dataset.
Other facilities in the same chain
CMS lists this facility under the chain Evergreen Healthcare Group — 44 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Facility data as of CMS processing date 2026-08-01. CCN 435109.
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The Care File
Visit checklist — Firesteel Healthcare Center
1120 East 7th Avenue, Mitchell, SD 57301 · (605) 996-6526
Health inspection rating 1/5 · CMS overall 1/5· Fines (3y): $153,308
Most serious findings on record:
▲ Dec 18, 2025 (F-0689, Actual harm, isolated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Dec 18, 2025 (F-0740, Actual harm, isolated): The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
▲ Apr 25, 2025 (F-0880, Actual harm, pattern): 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.
Questions for the administrator:
☐ "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?"
☐ "Your weekend nurse staffing is reported below the South Dakota midpoint — how does the weekend schedule differ from a weekday?"
☐ "Can I see the plan of correction for the findings in your most recent state inspection?"
☐ "CMS reports 55% total nursing staff turnover here — who on the care team has been with you longest?"
☐ "The ownership record on file lists 30 owning or managing parties — who makes the decisions about staffing levels?"
☐ "Can I visit again unannounced, at a mealtime or on a weekend?"
While you're there, notice:
☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)
Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 435109 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)