Firesteel Healthcare Center: Missing Opioids Uninvestigated - SD
The medication, a schedule II opioid painkiller considered one of the most potent in clinical use, was prescribed for a single resident. The pharmacy confirmed it had been sent to the facility. It was never returned. What happened to it between Thursday afternoon and Friday morning remains unknown.
The licensed practical nurse who signed for the shipment, identified in inspection records as LPN S, took the 60 tablets to the Hall 400 medication room but did not log them or secure them in the locked medication cart. The facility's own policy required schedule II medications to be kept in separately locked, permanently affixed compartments. That step was skipped.
Then a second nurse, LPN R, saw the medication sitting in the room and placed it near LPN S rather than locking it away. Then a certified medication aide, identified as CMA T, saw the medication in the room and also left it where it was, without telling anyone, before finishing her shift and going home.
Three people. The same bottle of opioids. Nobody moved it into the locked drawer.
When CMA T returned the next day, she looked for the medication and could not find it. She told the nurse. A facility-wide search followed. The medication was not found anywhere in the building.
The director of nursing, identified as DON B, was notified on March 21. She assembled staff and searched the facility herself. She conducted interviews. The staff members she identified as directly responsible, LPN S for failing to properly check in and secure a controlled substance, were terminated. The facility notified leadership, authorities, and the resident.
But the investigation had a significant gap. The facility had security cameras. DON B told inspectors during a May 27 interview that she did not think to review the footage after the medication went missing. She acknowledged she was not sure how long the footage was retained.
She found out later. The administrator, identified as Administrator A, told inspectors in a separate interview that the camera system stored 30 days of footage. The incident occurred on March 20 and 21. By the time anyone thought to look, the footage was gone.
The inspection was conducted on May 27 and 28, more than two months after the medication disappeared. Whatever the cameras recorded during those hours in the Hall 400 medication room, and in whatever other areas of the facility the Dilaudid might have passed through, no longer exists.
DON B told inspectors something else during her interview. She said she had not been conducting medication audits for controlled substances before this incident. She began doing them only after a subsequent, separate incident involving morphine being diluted.
That detail is worth pausing on. The Dilaudid disappeared in March. The morphine dilution came later. Only after that second incident did the director of nursing begin auditing controlled medications. The inspection report does not specify when the morphine incident occurred or what the outcome was.
What the report does establish is that the facility's handling of controlled substances had systemic problems that extended beyond a single nurse's failure to lock a drawer. Multiple staff members encountered the unsecured medication and did nothing. The nurse who signed for the delivery did not follow the check-in process. The nurse who saw it afterward did not secure it. The medication aide who saw it did not report it. And the director of nursing, after discovering 60 tablets of a powerful opioid had vanished, did not review the one potential source of evidence that might have shown what happened to them.
The medication room was not exclusively accessible to the nurses involved. DON B confirmed that both certified medication aides and nurses held keys to the medication rooms. The inspection report does not specify how many staff members had access to the Hall 400 medication room or how many people may have passed through it between Thursday afternoon and Friday morning.
Dilaudid, the brand name for hydromorphone, is a synthetic opioid significantly more potent by weight than morphine. It is classified as a schedule II controlled substance, the same category as oxycodone, fentanyl, and methamphetamine, reflecting its recognized potential for abuse and addiction. The 60 tablets prescribed for the resident represented a supply that, if diverted, carried meaningful risk of harm.
The resident whose medication disappeared was notified of the incident. The inspection report does not describe what happened to that resident's pain management in the interim, or whether replacement medication was obtained and how quickly.
Federal inspectors cited the facility for failing to secure the controlled medication. The deficiency was classified as causing minimal harm or potential for actual harm, affecting few residents. The citation fell under the regulatory requirement that nursing facilities obtain the services of a licensed pharmacist, a category that encompasses proper medication storage and security.
The classification of minimal harm reflects the regulatory framework's focus on the resident whose care was directly affected. It does not address the broader question of where 60 tablets of a potent opioid went, or whether anyone at the facility took them.
That question was not answered during the inspection. It may not be answerable now. The cameras recorded whatever they recorded. The footage is gone. The staff members terminated for their role in the incident are no longer at the facility. The medication has not been recovered.
The resident whose name appears on that pharmacy shipping manifest, 60 tablets of Dilaudid 2 mg, received March 20, 2026, is identified in inspection records only as Resident 7. The report does not say whether they ever received medication to replace what was lost, or how long they went without it while staff searched the building and came up empty.
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 12, 2026 · Our methodology
FIRESTEEL HEALTHCARE CENTER in MITCHELL, SD was cited for violations during a health inspection on May 28, 2026.
The medication, a schedule II opioid painkiller considered one of the most potent in clinical use, was prescribed for a single resident.
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.