Firesteel Healthcare Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 106 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 56.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 62 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 125 beds and averages 107.1 residents a day — about 86% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.94 hrs/resident/day on weekends vs 3.69 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

33 citations, most serious first. The 18 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · Gcited before2025-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the staff provided supervision and accident prevention interventions according to the resident's care plans for one of one sampled resident (2) who fell and sustained multiple facial fractures when left unsupervised in the dining room by a nursing staff member and one of one sampled resident (4) who fell from a mechanical lift when being transferred by certified nursing assistant (CNA) L. Findings include:1. Review of the provider's 11/24/25 SD DOH FRI regarding resident 2 revealed:*On 11/24/25 at 1:45 p.m. resident 2 was found face down on the dining room floor.*The fall was not witnessed.*This was resident 2's third fall in the dining room.*Staff had left him in the dining room to finish eating his meal while they assisted other residents.*Upon a nurse assessment resident 2 had blood coming from his nose and a cut on the top of his…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-12-18 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review the provider failed to ensure one of one sampled resident (1) who committed suicide had received the necessary behavioral health services to treat a diagnosed serious mental illness.Findings include:1. Review of the provider's 12/11/25 SD DOH FRI regarding resident 1 revealed:*On 12/11/25 at 12:50 a.m. a CNA (certified nursing assistant) responded to resident 1's roommate's call light and found resident 1 hanging by a string around his neck off the side of the bed.*That CNA had assisted resident 1 with his urinal at approximately 11:00 p.m. during the routine two-hour rounds (periodic checking on residents' status and assistance needs).*The CNA notified the nurse, the nurse responded to resident 1's room and cut the string that the resident was hanging from.*At the time resident 1 was released from the side of the bed he was cyanotic (bluish discoloration of the skin, lips, or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2025-04-25 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) complaint intake review, observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *Hand hygiene practices by staff members BB, GG, and HH during two of two dining observations in two of three dining rooms. *Hand hygiene and personal protective equipment (PPE) use by three of three staff observed (L, M, and BB) during personal cares for one of one sampled resident (41), personal cares for one of one sampled resident (33) on contact precautions (which indicated staff should have worn gowns and gloves), and assisting with resident transportation for two of two sampled residents (33 and 85). Failure to follow infection control practices potentially contributed to a norovirus [a highly contagious virus that causes nausea, vomiting, and diarrhea] outbreak in April 2025 which included three residents (18, 40, and 76) with confirmed norovirus infections and at least forty-two additional residents (1, 2, 3, 4, 12, 13, 14, 16, 22, 23, 24, 25, 29, 30,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-25 · tag F0925 — failed to control pests — isolated
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and policy review, the provider failed to ensure effective pest control for flying ants for one of twenty-six sampled residents (91) who complained of flying ants in his room and ant bites on his back. Findings include: 1. Interview and observation on 4/23/25 at 10:56 a.m. with resident 91 in his room revealed he stated: *He was having a problem with flying ants in his room. *The problem was daily and he had killed 30 to 40 of the flying ants every day. *The maintenance guy thinks they are coming in from behind [the] heater that was located on the wall below the window in his room. *Every morning his bedside table was covered with them and four to five of the flying ants were in his bed. -He had bites all over his back from the flying ants. -Resident 91 lifted the back of his shirt and showed his back which appeared to have several small red marks on his mid back. *Resident 91 stated he had been having problems with the flying ants for several weeks. -He stated I…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, interview, and policy review, the provider failed to administer physician-ordered antibiotic treatment and monitoring for one of one resident (1) who had an infection and was readmitted to the hospital. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was 7 which indicated he had moderate cognitive impairment. *He had been hospitalized and returned to the facility on [DATE] with a diagnosis of clostridium difficile (an infection that causes inflammation of the colon and diarrhea). *He had an order for Vancomycin HCI Oral Suspension 50 milligrams (mg)/milliliter (ml) give 2.5ml by mouth four times a day (antibiotic to treat infection) for clostridium difficile. *Upon his re-admission the admitting team incorrectly entered his antibiotic order into the electronic medical record (EMR) system as…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety of one of one sampled resident (1) who had a fall from the full mechanical lift and required hospitalization for injuries the following day. The citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of provider's 10/4/24 DOH FRI resident 1 revealed: *On 10/4/24 at 11:30 a.m. resident fell from the full mechanical lift -Resident 1 was interviewed by staff and stated, it happened so fast I am not sure what happened. -Resident interview also indicated her legs went up in the air and head went down causing her to slide onto the floor on her back. -Her vital signs were taken and were within normal limits. -She complained of upper back pain. -She refused further evaluation. -Neuro checks (the assessment of mental status, coordination, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2024-09-17 · tag F0725 — failed to have enough nursing staff — isolated
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and resident rights review, the provider failed to ensure staff were available to promptly respond to call lights for seven of seven sampled residents (1, 2, 3, 4, 5, 8, and 9) who used call lights to alert staff of their assistance needs. Findings include: 1. Observation on 9/16/24 at 3:45 p.m. throughout the facility revealed there was: *A sit-to-stand lift (mechanical lift used to assist to a standing position for transfers) and total lift (a mechanical lift with a body sling used for transfers) located in the hallway between rooms [ROOM NUMBERS]. *A sit-to-stand lift located in the 400 hallway outside of room [ROOM NUMBER]. -The lift had two safety slings stacked on top of it. *Two sit-to-stand lifts and two total lifts located in the 200 hallway. *A sit-to-stand lift located in the 100 hallway. Interview on 9/16/24 at 3:50 p.m. with certified nursing assistant (CNA) C revealed: *She worked as a bath aide in the 400 and 500 hallways. *She would have completed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-05-30 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) complaint report review, record review, and interview, the provider failed to correctly administer medications as ordered for one of one sampled resident (1) who required hospitalization. Failure to administer medications as ordered may have contributed to resident 1's health condition and need for hospitalization. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of SD DOH complaint revealed resident 1 had not received his medications as ordered after his 1/10/24 admission to the facility and he required another hospitalization on 1/14/24 . Review of resident 1's electronic medical record (EMR) revealed: *He was hospitalized on [DATE] for the evaluation and treatment of hypokalemia (low potassium), falls, rib fractures, acute kidney injury, and dehydration. *On 1/10/24 he was admitted to the facility following the hospital stay. His diagnosis…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Potential for harm · E2026-05-28 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) complaint records, interview, and policy review, the provider failed to report an incident to the SD DOH within the required time frame regarding two of two sampled residents (1 and 6) who had a reportable incident. Findings include: 1. Review of the 2/24/26 SD DOH complaint report revealed resident 1 reported an allegation of verbal abuse and neglect by travel certified nursing assistant (CNA) C and travel CNA D on 2/24/26 at 6:12 p.m. via an email to the director of nursing (DON) B, and administrator A, and the South Dakota Department of Health (SD DOH) complaints department. In her email, resident 1 alleged that travel CNA C and travel CNA D had told her she should have better time management regarding her use of the call light because they were busy delivering meal trays to other residents when she activated her call light. Then, when the travel CNAs were assisting her from the toilet to her wheelchair, her bare buttocks touched the arm of her wheelchair and they refused to clean it. DON B responded by email to resident 1's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-28 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on interview, record review, document review, and South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, the provider failed to ensure the staff responded promptly to four of five sampled residents (1,2,4,and 5) who reported they had to wait a long time for their call light to be answered. Findings include: 1. Interview on 5/26/26 at 12:30 p.m. with resident 5 revealed he was admitted to the facility recently and was unhappy with the care he received from the staff. When he first came to the facility, he needed more assistance from the staff because his muscles were weaker at that time. His call lights were not answered quickly, and there were times that he was incontinent (involuntary urine or bowel leakage) before the staff arrived which embarrassed and upset him. Now that he was stronger, he avoided using his call light. He was frustrated with waiting for the staff to respond and said, they are here for me and not the other way around. 2. Review of resident 5's electronic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-28 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), document review, interview, and policy review, the provider failed to secure a controlled medication (medication with risk for abuse and addiction), for one of one sampled resdient (7)'s Dilaudid (an extremely potent schedule II prescription opioid painkiller) that was received at the facility on 3/20/26 was not accounted for the following day on 3/21/26. Findings include: 1. 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…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-18 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the provider failed to ensure one of one sampled resident (3) had a palm protector (a foam device that fits over the hand to prevent severe finger contractures (curling) from digging into the palm) applied as ordered by the physician for contracture management of his right hand. Findings include:1. Observation on12/17/25 at 4:00 p.m. of resident 3 revealed he was seated in his recliner with a blanket covering his lap. His hands were on top of the blanket. His right hand was curled tightly, with his fingers appearing to be digging into the palm of his hand. Observation and interview on 12/18/25 at 9:30 a.m. of resident 3 in his room revealed the fingers on his right hand were curled and closed tightly. There was no device to separate his fingers from the palm of his hand. When asked if he had something to help open his hand, he stated he only wore the device when he was working. 2. Review of resident 3's electronic medical record (EMR) revealed:*His admission date was 2/24/21.*His 8/22/25 Brief Interview of Mental Status assessment…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review, the provider failed to follow standard food safety practices to ensure: *Prepared foods were covered when stored in one of one walk-in cooler. *The food stored in the walk-in cooler was stored appropriately to prevent cross-contamination. *Potentially hazardous food was prepared, stored, and served at safe food temperatures for one of one observed meal service. Findings include: 1. Observation on 4/22/25 at 3:15 p.m. of the walk-in cooler in the kitchen revealed: *A tray of 21 individual servings of chocolate pudding in reusable dessert bowls on a tray rack that were not covered and were open to air. *A shelving unit that contained on its: -Top shelf a cardboard box containing a plastic package of sliced beef that was fully cooked and another cardboard box containing three plastic packages of sliced smoked fully-cooked ham. -Top shelf, a laminated sign zip tied which displayed Safe Refrigerator Storage . with a chart that directed to store: --Ready-to Eat Foods on the top shelf. --Raw Fish and Seafood on the second…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-25 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor 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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure a homelike environment that was free from foul odors for: *The physical therapy gym, the nurse's desk outside the physical therapy gym, and near the rehab dining room. *The area around the nurse's station on the 200-hallway. Findings include: 1. Interview on 4/22/25 at 3:27 p.m. with therapy director R revealed: *There was a sewer odor coming from the linen closet near the therapy gym. *A contracted company recently performed a smoke test to determine areas of poor ventilation. -Some fixes were made which helped decrease the sewer odor in one of the therapy gym rooms. -There were still periods where a sewer odor was lingering and noticeable. -The odor was worse in the morning, usually around 9:00 a.m. Interview on 4/22/25 at 5:22 p.m. with resident 30 in her room revealed: *She felt the sewer odor throughout the facility had been an issue for a long time. *She said that she was able to smell the same sewer odor on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-25 · tag F0625 — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to provide bed-hold notices to the resident or the resident's responsible party at the time of transfer to a hospital for four of four sampled residents (33, 52, 66, and 107) who had transferred to the hospital. Findings include: 1. Observation and interview on 4/22/25 at 5:06 p.m. with resident 52 in his room revealed: *He was sitting in his recliner. *He had a sling around his left arm and shoulder. *He stated he was in the hospital for four days earlier this month. Review of resident 52's electronic medical record (EMR) revealed: *He had a Brief Interview for Mental Status (BIMS) assessment score of 15, which meant he was cognitively intact. *He had a fall on 4/4/25 and was transferred to the emergency room (ER). *His emergency contact had been notified on 4/4/25 of the need for an emergency room evaluation. *He was readmitted to the facility on [DATE]. *No documentation indicated he had received the bed hold policy…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-25 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure resident care plans were updated to reflect the current needs of three of twenty-six sampled residents (19, 33, and 85), such as resident preferences, skin wound prevention, and PTSD re-traumatizing prevention. Findings include: 1. Observation and interview on 4/23/25 at 2:28 p.m. with resident 19 in her room revealed: *She was lying on her back in bed. *There was a foot cradle over her feet, a device to lift the blankets away from a resident's feet. *She was very soft-spoken and indicated that she normally stays in bed each day. -She was terrified of falling. -She had a fall about a year ago and has stayed in bed since then. -She refuses to get out of bed. -She had no current skin issues or pressure injuries. Review of resident 19's current comprehensive care plan revealed: *She was admitted on [DATE]. *Her diagnoses included major depressive disorder (a mood disorder), and post-traumatic stress disorder (PTSD). *Her care plan…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-25 · tag F0847 — pattern
  Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, resident admission packet review, and policy review, the provider failed to ensure residents or their representatives fully understood the binding arbitration agreement process for two of three sampled residents (66 and 89). Findings include: 1. Review of the provider's record of residents or their representatives who had entered into a binding arbitration agreement revealed: *Resident 66 admitted on [DATE] and signed the binding arbitration agreement that same day. *Resident 89 admitted on [DATE] and his wife signed the binding arbitration agreement on 3/4/25. That form had an area to checkmark I Accept or I Decline and his wife had marked the box next to I Accept. *There was no checkmark for I Accept or I Decline on resident 66's binding arbitration agreement form. 2. Interview on 4/23/25 at 8:31 a.m. with social services director (SSD) E revealed the provider's parent company recently revised the binding arbitration agreement form to include the I Accept or I Decline options…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-25 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and policy review, the provider failed to identify, implement, and document quality assurance and performance improvement (QAPI) plans of action to correct identified infection control deficiencies for three of three months reviewed (January through April 2025) related to hand hygiene and personal protective equipment (PPE) compliance benchmarks. Findings include: 1. Observations and interviews made throughout the survey from 4/22/25 through 4/25/25 revealed that there were issues regarding hand hygiene and PPE compliance, which potentially contributed to the outbreak of a gastrointestinal illness that affected several residents and staff. Refer to F880. 2. Interview and record review on 4/25/25 at 11:19 a.m. with administrator A regarding their quality assurance and performance improvement (QAPI) activities revealed: *Administrator A reviewed their QAPI data on an Excel spreadsheet with the surveyor. *Their QAPI committee met at least monthly to review data and quality measures. -During their meetings, they reviewed the previous month's audits and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$153,308 in federal fines across 6 penalties.

• $42,510 — penalty dated 2025-12-18
• $46,137 — penalty dated 2025-04-25
• $34,320 — penalty dated 2024-11-26
• $6,788 — penalty dated 2024-10-17
• $15,041 — penalty dated 2024-09-17
• $8,512 — penalty dated 2024-05-30

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 30 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $194K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD