Firesteel Healthcare: Resident Falls From Lift - SD
The incident at Firesteel Healthcare Center on January 11 exposed widespread problems with the facility's sit-to-stand lifts, including missing safety clips, malfunctioning equipment, and staff who routinely skipped basic safety procedures.
Resident 2, who was cognitively intact, confirmed to inspectors that the strap around his midsection had been "very loose" during the fall. "Sometimes they tighten the strap and sometimes they don't," he said.
The aide working that night, CNA C, admitted she had not fastened the leg strap behind his legs and could not recall if she had tightened the mid-body strap as he stood. She also attempted the transfer alone, despite care plan instructions requiring two staff members.
"He stood up and then slid down, and she tried to place him in his wheelchair and called for the nurse," according to the inspection report. The nurse arrived as the aide lowered the resident to the floor.
No injuries occurred, but the resident had to use a full-body lift afterward. "I hate that thing," he told inspectors.
When inspectors observed another transfer with the same resident days later, two aides again failed to adjust the loose safety strap. The resident confirmed the strap remained "very loose" throughout the transfer.
CNA L, who participated in the observed transfer, stated the lift sling "should be tightened" but could not recall if she had done so. Her colleague, CNA D, similarly could not remember if the belt had been tight, saying "He already had the sling on."
The problems extended far beyond individual staff errors. Inspectors found six of the facility's eight sit-to-stand lifts were missing required safety clips where slings attach to the equipment.
Three lifts had been identified by staff as malfunctioning, slowly lowering residents back down while they attempted transfers. Physical therapy notes documented multiple instances where lifts "lost ability to maintain the standing position" with the 365-pound resident, despite his weight being well under the 500-pound capacity.
One lift was missing both required rubber clips. Another had been taken out of service after inspectors found it was missing clips and lowering residents during transfers.
Maintenance supervisor MS E admitted he had not been notified of the missing parts, despite conducting monthly inspections. "There hasn't been anything mechanically wrong with the lifts," he claimed, even as staff reported ongoing problems.
The maintenance checklist failed to include inspection of the metal clips that the manufacturer's instructions specifically required checking. Executive director A confirmed no mechanical lift repair requests had been entered into the facility's work order system since November 1.
Physical therapist PT M had been working with the resident after his fall, trying to determine if equipment failure or user error caused the incident. His treatment notes documented systematic problems: "Staff needs to have education and training in correct use" and "at least one [lift] loses its ability to maintain the standing position."
On January 15, therapy notes recorded: "Use of 500# heavy wt [lift] reveals the machine malfunctioning today and lowering pt when it is intended for maintaining the position."
The therapist identified only one lift that could safely be used with the resident, marking it with a small black X. Even that equipment required trials with different batteries due to suspected power issues causing the lifts to drop residents.
Director of nursing DON B acknowledged she had expected two staff to transfer the resident and initiated staff education after the incident. However, she had conducted no audits of lift usage or condition and was unaware that staff had concerns about three different lifts descending with heavier residents.
The resident's care plan contained contradictory information, with special instructions indicating "stand aid with 2 assist" while the care plan itself stated "Total lift with two assists." The plan also failed to specify which of the facility's lifts should be used for his transfers.
Resident 3, who used a different lift, reported that a metal clip had been missing "for a long time" but she had not told anyone about the broken equipment.
The manufacturer's operator instructions were clear about safety requirements: "For the safety of the patient, securely fasten the safety strap around the patient's torso" and "simultaneously tighten the safety strap buckled around their torso" as the resident is raised.
After the inspection, the facility repaired five lifts by installing required clips and took one malfunctioning unit out of service. Staff received additional training on proper lift procedures.
The resident returned to using sit-to-stand lifts under physical therapy supervision, but only with the one piece of equipment that had proven reliable and only with two staff members present.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Firesteel Healthcare Center from 2025-01-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
FIRESTEEL HEALTHCARE CENTER in MITCHELL, SD was cited for violations during a health inspection on January 22, 2025.
Resident 2, who was cognitively intact, confirmed to inspectors that the strap around his midsection had been "very loose" during the fall.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at FIRESTEEL HEALTHCARE CENTER?
- Resident 2, who was cognitively intact, confirmed to inspectors that the strap around his midsection had been "very loose" during the fall.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MITCHELL, SD, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from FIRESTEEL HEALTHCARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 435109.
- Has this facility had violations before?
- To check FIRESTEEL HEALTHCARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.