Firesteel Healthcare Center
FIRESTEEL HEALTHCARE CENTER in MITCHELL, SD — inspection on May 28, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
revealed, The Center immediately reports all suspected and/or allegations of abuse, neglect, and
The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law.as follows: Immediately but not later than 2 hours-All allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that cause the allegation involve abuse or result in serious bodily injury.
Note-reporting requirements are based on real clock time, not business hours.
The Center reports the results of all investigations to the Executive Director and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident.
The Center identifies staff responsible for implementation of corrective actions, expected date of implementation, and those responsible for monitoring.
Additional training is conducted with staff, and staff competency is evaluated as necessary.
Failure to report suspicion or allegations of abuse timely by staff will result in disciplinary action up to and including termination.
435109 05/28/2026
Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301
confirmed she had discovered resident 5's condom catheter tubing and bag was stored inappropriately
regarding his catheter care instructions, and a new nurse may not know what to do.
The catheter
provider's resident handbook revealed In a spirit of partnership, we design care plans that embrace your individual preferences, desires, and needs to the best of our ability.
Here are some standard skilled nursing services you may receive: 24-hour clinical care, comprehensive wound care, post-acute care, intravenous and enteral therapies, restorative nursing care .catheter care. 7.
Review of the provider's revised 3/19/25 Infection Control Policy revealed The objectives of facility infection control policies, protocols, and practices are to .support maintenance of a safe, sanitary, and comfortable environment for personnel, residents, and visitors.
435109 05/28/2026
Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301
Review of the provider's 3/20/26 SD DOH FRI revealed on 3/21/26 resident 7's Dilaudid was unaccounted for.
The Dilaudid was received and signed for by licensed practical nurse (LPN) S from the pharmacy.
That Dilaudid was taken by LPN S to the Hall 400 medication room, but was not properly signed or secured in the locked medication cart.
The next day, on 3/21/26, the certified medication could not be found by the medication aide (CMA) T, and she notified the nurse.
The medication was confirmed to be missing after a facility-wide search was completed.
The pharmacy confirmed the medication was sent to the facility and had not been returned.
Leadership, authorities, and resident 7 was notified of the incident.
Review of the pharmacy shipping manifest revealed resident 7's Dilaudid 2 mg (milligram) was received at the facility in the quantity of 60 tablets on 3/20/26. 3.
Interview on 5/27/26 at 3:30 p.m. with director of nursing (DON) B revealed she was notified of the missing medication on 3/21/26, and she, along with other staff, completed a facility-wide search for that medication.
She had completed staff interviews, and those who were immediately involved with the signed-in medication and not securing it were terminated for not following the facility process of checking in a controlled medication and securing it.
The medication was signed in as received at the front desk from the pharmacy and left in the locked medication room.
The medication was not locked in the locked medication cart drawer as it should have been.
The CMA had seen the medication in the medication room, but did not put the medication into the locked medication cart drawer or tell anyone before she left. DON B stated LPN R had seen the medication and placed it by LPN S, but did not lock it up. DON B acknowledged that the medication should have been double locked in the medication cart.
She did not think to view the camera footage and was not sure how long the footage was available.
The CMAs and nurses had keys to the medication rooms. DON B stated she did not completed medication audits until they had another incident of a controlled medication of morphine being diluted. 4.
Interview on 10/28/26 at 10:51 a.m. with administrator A revealed that the facility camera footage went back 30 days, and any footage of the incident was no longer available. 5.
Review of the provider's undated Controlled Medication Storage policy revealed that scheduled II-V medications must be maintained in separately locked, permanently affixed compartments.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.