Nursing Care Index

Firesteel Healthcare Center

Mitchell, Davison County, South Dakota · CCN 435109 · For-profit (LLC) · part of Evergreen Healthcare Group (44 facilities, chain average 2.5 stars)

CMS rates Firesteel Healthcare Center 1 of 5 overall as of August 2026. 125 certified beds, 107 residents a day on average. 33 citations on record from the current inspection cycles, 8 involving actual harm; 6 fines totalling $153,308.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★☆☆☆ 2 of 5
Quality measures★★☆☆☆ 2 of 5
Quality: long-stay / short-stay2 / 2 of 5

Staffing

Total nurse staffing3.4726 hours per resident per day
Registered nurses0.50859 hours per resident per day
Weekend total2.94128 hours per resident per day
Nursing staff turnover55% (registered nurses 46.2%)

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-05-28
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-28
2026-05-28
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-01
2026-05-28
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-28
2025-12-18
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2026-01-09
2025-12-18
complaint survey
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies · tag F0740
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-12-22
2025-12-18
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-22
2025-04-25
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
H Actual harm that is not immediate jeopardy; pattern Deficient, Provider has date of correction
2025-05-20
2025-04-25 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies · tag F0925
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-05-20
2025-04-25 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-05-20
2025-04-25
complaint survey
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.
Resident Rights Deficiencies · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-20
2025-04-25
complaint survey
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.
Resident Rights Deficiencies · tag F0625
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-20
2025-04-25 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-20
2025-04-25 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · tag F0847
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-20
2025-04-25
complaint survey
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-20
2025-04-25 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-20
2025-01-22
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-01-21
2025-01-22
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-14
2025-01-02
complaint survey
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.
Nutrition and Dietary Deficiencies · tag F0803
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-30
2025-01-02
complaint survey
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2024-12-18
2025-01-02
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-30
2025-01-02
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-30
2024-11-26
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-12-27
2024-10-17
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Past Non-Compliance
2024-10-04
2024-09-17
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-10-12
2024-05-30
complaint survey
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
G Actual harm that is not immediate jeopardy; isolated Past Non-Compliance
2024-01-25
2024-04-23
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-30
2024-01-04 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-02-10
2024-01-04 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-10
2024-01-04 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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-10
2023-01-31 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-03-09
2023-01-31 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-03-09
2023-01-31 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Nutrition and Dietary Deficiencies · tag F0801
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-03-09
2023-01-31 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-03-09

Fines and payment denials

DatePenaltyAmount
2025-12-18Fine$42,510
2025-04-25Fine$46,137
2024-11-26Fine$34,320
2024-10-17Fine$6,788
2024-09-17Fine$15,041
2024-05-30Fine$8,512

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Pacific Northwest Snf Operations Holdings (Sd) LLC
Organization
5% or greater direct ownership interest100%2023-08-31
Ch Pacific Northwest Holdings LLC
Organization
adp of the snf2023-08-31
Couve Financial Services LLC
Organization
adp of the snf2025-03-07
Couve Healthcare Consulting LLC
Organization
adp of the snf2025-03-12
Firesteel Snf Operations, LLC
Organization
adp of the snf2025-07-31
Firesteel Snf Realty LLC
Organization
adp of the snf2025-05-13
Pacific Northwest Opco Management LLC
Organization
adp of the snf2025-03-07
South Dakota Snf Consulting LLC
Organization
adp of the snf2025-03-12
Witzcorp Global LLC
Organization
adp of the snf2023-08-31
Couve Financial Services LLC
Organization
operational/managerial control2023-08-31
Couve Healthcare Consulting LLC
Organization
operational/managerial control2023-08-31
Firesteel Snf Operations, LLC
Organization
operational/managerial control2023-08-31
Pacific Northwest Opco Management LLC
Organization
operational/managerial control2023-08-31
South Dakota Snf Consulting LLC
Organization
operational/managerial control2023-08-31
Bossman, Ann
Individual
adp of the snf2023-08-31
Herzka, Yisroel
Individual
adp of the snf2023-08-31
Lowe, Leonor
Individual
adp of the snf2023-08-31
Mirkovic, Petar
Individual
adp of the snf2023-08-31
Peterson, Scott
Individual
adp of the snf2023-08-31
Spielman, Shimon
Individual
adp of the snf2023-08-31
Yenowitz, Yitzchok
Individual
adp of the snf2023-08-31
Spielman, Shimon
Individual
corporate officer2023-08-31
Yenowitz, Yitzchok
Individual
corporate officer2023-08-31
Lowe, Leonor
Individual
managing control - governing body2023-08-31
Bossman, Ann
Individual
operational/managerial control2023-08-31
Lowe, Leonor
Individual
operational/managerial control2023-08-31
Mirkovic, Petar
Individual
operational/managerial control2023-08-31
Peterson, Scott
Individual
operational/managerial control2023-08-31
Spielman, Shimon
Individual
operational/managerial control2023-08-31
Yenowitz, Yitzchok
Individual
operational/managerial control2023-08-31

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Davison County.