A
AVERA BRADY HEALTH AND REHAB
89/100 score
1.44 hrs RN staffing
3 deficiencies
FIRESTEEL HEALTHCARE CENTER
1120 EAST 7TH AVENUE, MITCHELL, SD 57301
F
Facility Assessment
Inspectors recorded 8 citations at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — review inspection history before visiting.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.40 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
30
Outstanding
0
Actual harm or worse (G–L)
8
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★☆☆☆ (2/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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13/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
8 actual harm issues found among 30 total deficiencies. 30 corrected.
Most recent inspection (April 25, 2025)
E
Potential harm — pattern
F0847
Status: Corrected
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
E
Potential harm — pattern
F0867
Status: Corrected
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
G
Actual harm — isolated
F0925
Status: Corrected
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
H
Actual harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
G
Actual harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2026
G
Actual harm — isolated
F0740
Status: Corrected
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 22, 2025
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 22, 2025
E
Potential harm — pattern
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
D
Potential harm — isolated
F0554
Status: Corrected
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
E
Potential harm — pattern
F0584
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
E
Potential harm — pattern
F0625
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
Inspection cycle 2 (January 4, 2024)
F
Potential harm — widespread
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2024
G
Actual harm — isolated
F0725
Status: Corrected
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024
E
Potential harm — pattern
F0803
Status: Corrected
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2025
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2024
G
Actual harm — isolated
F0760
Status: Corrected
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Past Non-Compliance, corrected January 25, 2024
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected January 21, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2025
G
Actual harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024
G
Actual harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected October 4, 2024
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 30, 2024
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2025
D
Potential harm — isolated
F0583
Status: Corrected
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Past Non-Compliance, corrected December 18, 2024
D
Potential harm — isolated
F0584
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2024
Inspection cycle 3 (January 31, 2023)
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 9, 2023
D
Potential harm — isolated
F0801
Status: Corrected
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 9, 2023
D
Potential harm — isolated
F0758
Status: Corrected
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 9, 2023
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 9, 2023
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