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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G8 | H1 | I· |
| Potential harm | D20 | E17 | F2 |
| Minimal | A· | B· | C1 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jul 30, 2026 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| Jul 30, 2026 | Health | Health Complaint, Health Standard | 10 | Actual harm | — | Open → |
| May 28, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Dec 18, 2025 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Apr 25, 2025 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Apr 25, 2025 | Health | Health Complaint, Health Standard | 9 | Actual harm | — | Open → |
| Jan 22, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 2, 2025 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Nov 26, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Oct 17, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Sep 17, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| May 30, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Apr 23, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 4, 2024 | Fire safety | Fire Safety Standard | 1 | Minimal | 1 | Open → |
| Jan 4, 2024 | Health | Health Standard | 3 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Dec 18, 2025 | Civil money penalty (fine) | $42,510 | — | 435109|Fine|138113 |
| Apr 25, 2025 | Civil money penalty (fine) | $46,137 | — | 435109|Fine|100286 |
| Nov 26, 2024 | Civil money penalty (fine) | $34,320 | — | 435109|Fine|100258 |
| Oct 17, 2024 | Civil money penalty (fine) | $6,788 | — | 435109|Fine|100245 |
| Sep 17, 2024 | Civil money penalty (fine) | $15,041 | — | 435109|Fine|100236 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G8 | H1 | I· |
| Potential harm | D20 | E17 | F2 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 30, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Aug 20, 2026 | Complaint |
| Jul 30, 2026 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 20, 2026 | |
| Jul 30, 2026 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
43 facilities in 6 states. CMS chain ID 846.
Chain average overall rating (CMS): 2.3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Pacific Northwest SNF Operations Holdings (Sd) LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 31, 2023 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Pacific Northwest SNF Operations Holdings (Sd) LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 31, 2023 |
| Leonor Lowe | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Aug 31, 2023 |
| Couve Financial Services LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Couve Healthcare Consulting LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Riverview Healthcare Center 611 East 2nd Ave, Flandreau, SD 57028 CCN 435086SFF CandidateAbuse icon | 63 | Aug 28, 2026 | 644 IJ11 harm |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Avera Brady Health and Rehab 500 S Ohlman, Mitchell, SD 57301 CCN 435061 | 3.2 km | 84 | Apr 27, 2026 | 9 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 435109 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 435109 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| May 30, 2024 | Civil money penalty (fine) | $8,512 | — | 435109|Fine|100218 |
| K-0321 |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety |
| E · Potential harm Pattern |
| Corrected Aug 20, 2026 |
| Jul 30, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 20, 2026 |
| Jul 30, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 20, 2026 |
| Jul 30, 2026 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Aug 20, 2026 |
| May 28, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 28, 2026 | Complaint |
| May 28, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 1, 2026 | Complaint |
| May 28, 2026 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 28, 2026 | Complaint |
| Dec 18, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 9, 2026 | Complaint |
| Dec 18, 2025 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Dec 22, 2025 | Complaint |
| Dec 18, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 22, 2025 | Complaint |
| Apr 25, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | H · Actual harm Pattern | Corrected May 20, 2025 | Complaint |
| Apr 25, 2025 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | G · Actual harm Isolated | Corrected May 20, 2025 |
| Apr 25, 2025 | K-0226 | Have horizontal exits used in accordance with safety requirements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 20, 2025 |
| Apr 25, 2025 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 20, 2025 |
| Apr 25, 2025 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 20, 2025 |
| Apr 25, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 20, 2025 |
| Apr 25, 2025 | F-0584 | 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 · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 20, 2025 | Complaint |
| Apr 25, 2025 | F-0625 | 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 · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 20, 2025 | Complaint |
| Apr 25, 2025 | F-0656 | 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 · Clinical care | E · Potential harm Pattern | Corrected May 20, 2025 |
| Apr 25, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 20, 2025 |
| Apr 25, 2025 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected May 20, 2025 |
| Apr 25, 2025 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected May 20, 2025 | Complaint |
| Jan 22, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Past non-compliance Jan 21, 2025 | Complaint |
| Jan 22, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 14, 2025 | Complaint |
| Jan 2, 2025 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Past non-compliance Dec 18, 2024 | Complaint |
| Jan 2, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 30, 2025 | Complaint |
| Jan 2, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 30, 2025 | Complaint |
| Jan 2, 2025 | F-0803 | 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 · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jan 30, 2025 | Complaint |
| Nov 26, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Dec 27, 2024 | Complaint |
| Oct 17, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Past non-compliance Oct 4, 2024 | Complaint |
| Sep 17, 2024 | F-0725 | 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 · Staffing & supervision | G · Actual harm Isolated | Corrected Oct 12, 2024 | Complaint |
| May 30, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | G · Actual harm Isolated | Past non-compliance Jan 25, 2024 | Complaint |
| Apr 23, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 30, 2024 | Complaint |
| Jan 4, 2024 | F-0584 | 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 · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 10, 2024 |
| Jan 4, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Feb 10, 2024 |
| Jan 4, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Feb 10, 2024 |
| Jan 4, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Plan of correction, not yet verified Feb 10, 2024 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.98 (case-mix index 1.25).
| not provided |
| Aug 31, 2023 |
| Firesteel SNF Operations, LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Pacific Northwest Opco Management LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| South Dakota SNF Consulting LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Ann Bossman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Leonor Lowe | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Petar Mirkovic | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Scott Peterson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Shimon Spielman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Yitzchok Yenowitz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Shimon Spielman | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Aug 31, 2023 |
| Yitzchok Yenowitz | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Aug 31, 2023 |
| Ch Pacific Northwest Holdings LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Couve Financial Services LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 7, 2025 |
| Couve Healthcare Consulting LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 12, 2025 |
| Firesteel SNF Operations, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 31, 2025 |
| Firesteel SNF Realty LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 13, 2025 |
| Pacific Northwest Opco Management LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 7, 2025 |
| South Dakota SNF Consulting LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 12, 2025 |
| Witzcorp Global LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Ann Bossman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Yisroel Herzka | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Leonor Lowe | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Petar Mirkovic | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Scott Peterson | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Shimon Spielman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| Yitzchok Yenowitz | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 31, 2023 |
| $166k |
| Wheatcrest Hills Healthcare Center 1311 Vander Horck St, Britton, SD 57430 CCN 435105 | 60 | Aug 19, 2026 | 173 harm | $38k |
| Fountain Springs Healthcare 2000 Wesleyan Blvd, Rapid City, SD 57702 CCN 435110 | 90 | Feb 12, 2026 | 191 IJ1 harm | $23k |
| Palisade Healthcare Center 920 4th St, Garretson, SD 57030 CCN 435115SFF CandidateAbuse icon | 55 | Apr 16, 2026 | 371 IJ4 harm | $250k |
| Prairie View Healthcare Center 401 South First Avenue, Woonsocket, SD 57385 CCN 435118 | 42 | Aug 27, 2026 | 161 harm6 open | $8,512 |