Firesteel Healthcare Center in Mitchell, SD has a 1 out of 5 overall rating, with 1-star health inspections and 2-star staffing and quality measures. Reported nurse staffing is below the federal benchmark (3.56 vs. 4.1 hours per resident per day), and the facility has had $176,198 in fines in the last 24 months plus a recent federal penalty.
Last inspection: December 18, 2025Penalties, last 24 months: $176,198recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.5583.
Staffing detail
Registered nurses
0.46
Licensed practical nurses
0.59
Nurse aides
2.51
Weekend nursing
3.06
Hours per resident per day.
Total staff turnover: 58%
Registered nurse turnover: 46%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
23.6%Worsening
Residents with a fall causing major injury
4.4%Improving
Residents with pressure ulcers (bedsores)
3.8%Improving
Residents with a urinary tract infection
2.6%Worsening
Residents who lost too much weight
2.4%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
19.9%Worsening
Residents whose ability to walk got worse
19.2%Worsening
Show all measures
Long-stay residents on antianxiety or sleep medication
14.9%Steady
Short-stay residents newly given an antipsychotic
3.2%Improving
Residents with a long-term catheter
0.3%Improving
Residents with new or worsening incontinence
25.4%Improving
Residents with depressive symptoms
0.3%Worsening
Long-stay residents given the seasonal flu vaccine
97.1%Steady
Long-stay residents given the pneumonia vaccine
89.4%Worsening
Short-stay residents given the seasonal flu vaccine
75.3%Steady
Short-stay residents given the pneumonia vaccine
57.9%Worsening
What the inspectors found
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited April 2025 — limited pattern, actual harm.
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F-Tag 880 — 42 CFR §483.80(a) — S/S: H
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited December 2025 — isolated incident, actual harm.
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F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The nursing home failed to ensure residents received the behavioral health care and services they needed. Cited December 2025 — isolated incident, actual harm.
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F-Tag 740 — 42 CFR §483.40 — S/S: G
The nursing home failed to make sure it had a pest control program to prevent or deal with mice, insects, and other pests. Cited April 2025 — isolated incident, actual harm.
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F-Tag 925 — 42 CFR §483.90 — S/S: G
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited November 2024 — isolated incident, actual harm.
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F-Tag 684 — 42 CFR §483.25 — S/S: G
Recent history
STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
PENALTY
A federal fine of $65,400 was recorded.
INSPECTION
Health inspection found 3 health deficiencies.
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PENALTY
A federal fine of $46,137 was recorded.
INSPECTION
Health inspection found 9 health deficiencies.
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INSPECTION
Health inspection found 2 health deficiencies.
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PENALTY
A federal fine of $34,320 was recorded.
PENALTY
A federal fine of $6,788 was recorded.
PENALTY
A federal fine of $15,041 was recorded.
PENALTY
A federal fine of $8,512 was recorded.
Penalties & enforcement
On record with Medicare: 6 fines · $176,198 in total fines.
Federal fine
Dec 18, 2025
$65,400
Federal fine
Apr 25, 2025
$46,137
Federal fine
Nov 26, 2024
$34,320
Federal fine
Oct 17, 2024
$6,788
Federal fine
Sep 17, 2024
$15,041
Federal fine
May 30, 2024
$8,512
Operator & ownership
Ownership
For profit - Limited Liability company
Chain
Part of EVERGREEN HEALTHCARE GROUP · 43 homes · 2.4 stars avg
Occupancy
113.7 residents on an average day (91% of 125 beds)
Resident voice
Resident council
Medicare history
Certified for 28 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.