Facility Watch Inspection records for every certified US nursing home

Palisade Healthcare Center

920 4th ST
Garretson, SD 57030
(605) 594-3466

Special Focus Facility — SFF CandidateAbuse icon
CCN
435115
Certified beds
55
Ownership
For profit - Corporation
Chain
Evergreen Healthcare Group

Nurse staffing

3.94
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.64 hours per resident per day

Nursing staff turnover: 58% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 16, 2026

3 citations · from a complaint investigation · Health
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has plan of correction · corrected May 6, 2026
E
F0919 No actual harm with potential for more than minimal harm · Pattern

Make sure that a working call system is available in each resident's bathroom and bathing area.

Deficient, Provider has plan of correction · corrected May 6, 2026
H
F0600 Actual harm · Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has plan of correction · corrected May 6, 2026

Inspected November 19, 2025

1 citation · from a complaint investigation · Health
J
F0684 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected November 20, 2025

Inspected September 17, 2025

1 citation · from a complaint investigation · Health
G
F0689 Actual harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected September 18, 2025

Inspected August 7, 2025

7 citations · from a complaint investigation · Health
D
F0582 No actual harm with potential for more than minimal harm · Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Deficient, Provider has date of correction · corrected August 22, 2025
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Past Non-Compliance · corrected April 25, 2025
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected August 22, 2025
E
F0761 No actual harm with potential for more than minimal harm · Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Deficient, Provider has date of correction · corrected August 22, 2025
E
F0804 No actual harm with potential for more than minimal harm · Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected August 22, 2025
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected August 22, 2025
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected August 22, 2025

Inspected March 12, 2025

2 citations · from a complaint investigation · Health
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected March 28, 2025
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 28, 2025

Inspected November 26, 2024

2 citations · from a complaint investigation · Health
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected December 16, 2024
G
F0600 Actual harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected December 16, 2024

Inspected August 7, 2024

1 citation · from a complaint investigation · Health
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected September 13, 2024

Inspected March 18, 2024

8 citations · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0578 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0909 No actual harm with potential for more than minimal harm · Isolated

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0695 No actual harm with potential for more than minimal harm · Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected April 11, 2024
F
F0584 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected April 11, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected April 11, 2024

Inspected December 28, 2023

1 citation · from a complaint investigation · Health
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected February 1, 2024

Inspected March 8, 2023

3 citations · Health
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected April 14, 2023
E
F0657 No actual harm with potential for more than minimal harm · Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected April 14, 2023
E
F0678 No actual harm with potential for more than minimal harm · Pattern

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Deficient, Provider has date of correction · corrected April 14, 2023

Penalties

DateTypeAmount
November 19, 2025Fine$122,476
September 17, 2025Fine$8,608
August 7, 2025Fine$11,713
November 26, 2024Fine$12,149

Ownership transfers

EffectiveSellerBuyer
08/31/2023Empres at Garretson LLCPalisade SNF Operations, LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.