Palisade Healthcare Center
920 4th St · Garretson, SD · 57030 · 6055943466
55 certified beds For profit - Corporation Chain: Evergreen Healthcare Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $154,946 in fines in the last 24 months.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$154,946 in federal fines in the last 24 months
4 fines — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.41 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.56 | 0.55–0.75 |
| Weekend hours / resident-day | 2.80 | ≈ weekday level |
| Nursing turnover / year | 58% | median 45% |
| Fines (3-yr window) | 4 · $154,946 |
Inspection citations (29 in the current record)
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Actual harm · H April 16, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 16, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 6, 2026 · Infection Control
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Potential for harm · E April 16, 2026 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected May 6, 2026 · Environmental
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Immediate jeopardy · J November 19, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 20, 2025 · Quality of Life and Care
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Actual harm · G September 17, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 18, 2025 · Quality of Life and Care
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Actual harm · G August 7, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected August 22, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 7, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected August 22, 2025 · Resident Rights
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Potential for harm · E August 7, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected August 22, 2025 · Nursing and Physician Services
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Potential for harm · E August 7, 2025
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.
Corrected August 22, 2025 · Pharmacy Service
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Potential for harm · E August 7, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected August 22, 2025 · Nutrition and Dietary
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Potential for harm · E August 7, 2025
Provide and implement an infection prevention and control program.
Corrected August 22, 2025 · Infection Control
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Potential for harm · D March 12, 2025 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 28, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 12, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 28, 2025 · Quality of Life and Care
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Actual harm · G November 26, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 16, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 26, 2024 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected December 16, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 7, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected September 13, 2024 · Pharmacy Service
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Potential for harm · D March 18, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 11, 2024 · Resident Rights
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Potential for harm · D March 18, 2024
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.
Corrected April 11, 2024 · Resident Rights
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Potential for harm · F March 18, 2024
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.
Corrected April 11, 2024 · Resident Rights
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Potential for harm · D March 18, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 11, 2024 · Resident Assessment and Care Planning
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Potential for harm · E March 18, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected April 11, 2024 · Quality of Life and Care
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Potential for harm · F March 18, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 11, 2024 · Nutrition and Dietary
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Potential for harm · E March 18, 2024
Provide and implement an infection prevention and control program.
Corrected April 11, 2024 · Infection Control
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Potential for harm · D March 18, 2024
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.
Corrected April 11, 2024 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 19, 2025 | Fine | $122,476 |
| September 17, 2025 | Fine | $8,608 |
| August 7, 2025 | Fine | $11,713 |
| November 26, 2024 | Fine | $12,149 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435115 · certified since October 1, 1998. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.