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.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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.