Firesteel Healthcare Center: Catheter Care Failures - SD
The resident, identified in inspection records as Resident 5, used a condom catheter. The tubing and bag connected to that catheter require specific handling: stored in a catheter bag, dated, and replaced on a weekly schedule. None of that had happened. The supplies were in the bathroom, undated, in no designated storage container.
The nurse who found them acknowledged the problem directly to inspectors. She replaced the supplies, placed them in a dated storage bag, and moved them to an appropriate location. But the discovery opened a second problem that the physical fix couldn't close.
She agreed, when inspectors pressed her, that the information documented in Resident 5's treatment administration record and care plan did not include enough detail about how his catheter care should be handled. A nurse coming onto a shift without prior familiarity with this resident, she said, would not know what to do.
That gap matters in a facility where staff rotate, where new hires take assignments before they've learned every resident's routine, and where a care plan is supposed to be the document that bridges that knowledge. Firesteel's own resident handbook, reviewed by inspectors during the visit, describes care plans as documents designed to "embrace your individual preferences, desires, and needs." Catheter care is listed explicitly among the skilled nursing services the facility promises to provide.
The facility's infection control policy, revised as recently as March 2025, states that the objectives of its infection control practices include supporting "a safe, sanitary, and comfortable environment for personnel, residents, and visitors." Catheter supplies stored without dating or proper containment work against that objective in a direct and measurable way. An undated bag cannot be changed on schedule. A bag changed on no schedule is a bag that creates infection risk.
Inspectors classified the harm level as minimal, with potential for actual harm. The finding affected some residents, not just Resident 5.
The complaint inspection was conducted May 28, 2026. Firesteel Healthcare Center is located at 1120 East 7th Avenue in Mitchell and operates under provider ID 435109.
What the record shows is a nurse who, once confronted with the problem, handled it correctly and spoke honestly about what the documentation failed to provide. What it also shows is that the failure existed before she walked into that bathroom, and that the care plan, the document meant to prevent exactly this kind of gap, had not been written to do its job.
Resident 5 remained in his room while his supplies sat stored the wrong way, in a facility that had pledged in writing to give him catheter care and had revised its infection control policy fourteen months before inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Firesteel Healthcare Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 11, 2026 · Our methodology
FIRESTEEL HEALTHCARE CENTER in MITCHELL, SD was cited for violations during a health inspection on May 28, 2026.
The resident, identified in inspection records as Resident 5, used a condom catheter.
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.