Map showing the location of FIRESTEEL HEALTHCARE CENTER in MITCHELL, South Dakota
1120 EAST 7TH AVENUE, MITCHELL, SD, 57301

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • South DakotaLowest tier among peers95 rated homes · average 2.9★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs SD avg
  • StaffingCan add or remove a star2★−1.5 vs SD avg
  • Quality measuresCan add or remove a star2★−0.9 vs SD avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersSD avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 7% of peersSD avg3.5★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 15% of peersSD avg2.9★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.45hrsAbove only 35% of peersSD avg3.89Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.40hrsAbove only 4% of peersSD avg0.80Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better50%Above only 43% of peersSD avg50%RN turnover46%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$135,641Above only 2% of peersSD avg$25,187Fines · denials5 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
30citations
11inspection dates
8actual harm (G–I)
0immediate jeopardy (J–L)
Dec 18, 2025most recent

Citations by monthJan 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 18, 20253 citationsCycle 1worst G · actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Dec 22, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jan 9, 2026
  3. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareG · isolatedCorrected Dec 22, 2025
Apr 25, 20259 citationsCycle 1worst H · actual harm$70,980
  1. F880Provide and implement an infection prevention and control program.Infection ControlH · patternCorrected May 20, 2025
  2. 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 RightsE · patternCorrected May 20, 2025
  3. F584Honor 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 RightsE · patternCorrected May 20, 2025
  4. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected May 20, 2025
  5. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected May 20, 2025
  6. F656Develop 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 PlanningE · patternCorrected May 20, 2025
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 20, 2025
  8. F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.AdministrationE · patternCorrected May 20, 2025
  9. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalG · isolatedCorrected May 20, 2025
Jan 22, 20252 citationsCycle 2worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jan 21, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 14, 2025
Jan 2, 20254 citationsCycle 2worst E · no actual harm
  1. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Dec 18, 2024
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 30, 2025
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 30, 2025
  4. F803Ensure 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 DietaryE · patternCorrected Jan 30, 2025
Nov 26, 20241 citationCycle 2worst G · actual harm$34,320
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Dec 27, 2024
Oct 17, 20241 citationCycle 2worst G · actual harm$6,788
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Oct 4, 2024
Sep 17, 20241 citationCycle 2worst G · actual harm$15,041
  1. F725Provide 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 ServicesG · isolatedCorrected Oct 12, 2024
May 30, 20241 citationCycle 2worst G · actual harm$8,512
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceG · isolatedCorrected Jan 25, 2024
Apr 23, 20241 citationCycle 2worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 30, 2024
Jan 4, 20243 citationsCycle 2worst F · no actual harm
  1. F584Honor 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 RightsD · isolatedCorrected Feb 10, 2024
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 10, 2024
  3. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Feb 10, 2024
Jan 31, 20234 citationsCycle 3worst D · no actual harm
  1. F801Employ 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 DietaryD · isolatedCorrected Mar 9, 2023
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 9, 2023
  3. F758Implement 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 ServiceD · isolatedCorrected Mar 9, 2023
  4. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 9, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.45hrsAbove only 35% of peers−0.44 vs SD avg
  • Registered nursesRN hours only0.40hrsAbove only 4% of peers−0.40 vs SD avg
  • Licensed practical nursesLPN hours0.57hrs
  • Nurse aidesCNA hours2.49hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.96hrs
  • South Dakota average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better50%Above only 43% of peersSD avg 50%
  • RN turnoverRegistered nurses only46%Not ranked by CMS
  • Administrators who leftIn the past year
  • Occupancy150 certified beds · ~113 residents a day76%Above only 19% of peersSD avg 84%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $135,641In fines
  • 5Fines
  • 0Payment denials
  • $25,187SD avg in fines
Above only 2% of peersFewer fines than 2% of rated homes in South Dakota

Actions on record

  1. Apr 25, 2025Civil money penalty$70,980
  2. Nov 26, 2024Civil money penalty$34,320
  3. Oct 17, 2024Civil money penalty$6,788
  4. Sep 17, 2024Civil money penalty$15,041
  5. May 30, 2024Civil money penalty$8,512

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Empres Operated by Evergreen42 facilities in the chain2.4★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Pacific Northwest SNF Operations Holdings (Sd) LLC
Indirect owners (5%+)
  • Ch Pacific Northwest Holdings LLC
  • Pacific Northwest SNF Operations Holdings, LLC
  • Witzcorp Global LLC
  • Yisroel Herzka
  • Yitzchok Yenowitz
Operational or managerial control
  • Couve Financial Services LLC
  • Couve Healthcare Consulting LLC
  • Firesteel SNF Operations, LLC
  • Pacific Northwest Opco Management LLC
  • South Dakota SNF Consulting LLC
  • Ann Bossman
  • Leonor Lowe
  • Petar Mirkovic
  • +4 more
Corporate officers
  • Shimon Spielman
  • Yitzchok Yenowitz

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 435109 · 1120 EAST 7TH AVENUE, MITCHELL, SD, 57301.
  • Percentiles compare this facility with every rated nursing home in South Dakota and Davison County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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