Palisade Healthcare Center
920 4th St, Garretson, SD 57030 · Minnehaha County · 55 certified beds · avg 49 residents/day · certified since Oct 1, 1998
Abuse citation flag (CMS)
Part of chain: EVERGREEN HEALTHCARE GROUP (44 facilities, chain avg rating 2.5★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Nov 19, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Apr 16, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: May 6, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 17, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 7, 2025 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 26, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 16, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 16, 2026 | ▲ H · Actual harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 19, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 17, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 7, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 7, 2025 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Aug 7, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 7, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 7, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 12, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Mar 12, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 26, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Aug 7, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 18, 2024 | F · Potential for harm, facility-wide | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 18, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 18, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 18, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 18, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 18, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Mar 18, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 18, 2024 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Dec 28, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Mar 8, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 8, 2023 | E · Potential for harm, repeated | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Mar 8, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | E |
| 2024 | 11 | 1 | G ▲ |
| 2025 | 11 | 3 | J ▲ |
| 2026 | 3 | 1 | H ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $154,946.
| Date | Type | Amount / length |
|---|---|---|
| Nov 19, 2025 | Fine | $122,476 |
| Sep 17, 2025 | Fine | $8,608 |
| Aug 7, 2025 | Fine | $11,713 |
| Nov 26, 2024 | Fine | $12,149 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.38 | 4.32 | 3.95 | bottom 12% in South Dakota; bottom 30% in the U.S. |
| Registered Nurse hours | 0.58 | 0.91 | 0.69 | bottom 11% in South Dakota; bottom 49% in the U.S. |
| Weekend total nurse staffing | 2.81 | 3.71 | 3.50 | bottom 10% in South Dakota; bottom 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.33 | 0.51 | 0.48 | bottom 18% in South Dakota; bottom 38% in the U.S. |
| Total nursing staff turnover (%) | 60.0 | 48.2 | 45.8 | bottom 17% in South Dakota; bottom 17% in the U.S. |
| RN turnover (%) | 40.0 | 34.7 | 42.9 | bottom 34% in South Dakota; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.16, RN 0.54, weekend 2.64. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Pacific Northwest SNF Operations Holdings (SD) LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/31/2023 |
| CH Pacific Northwest Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Cheeks, Donald | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/31/2023 |
| Cheeks, Donald | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Cheeks, Donald | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Couve Financial Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Couve Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/12/2025 |
| Couve Healthcare Consulting LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Couve Healthcare Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/12/2025 |
| Evans, Kayla | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/31/2023 |
| Evans, Kayla | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Evans, Kayla | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Herzka, Yisroel | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Pacific Northwest Opco Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Pacific Northwest Opco Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/12/2025 |
| Palisade SNF Operations, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Palisade SNF Operations, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/29/2025 |
| Palisade SNF Realty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/12/2025 |
| Parker, Lourdes | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Parker, Lourdes | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you show me the call buttons in the bathrooms and bathing areas, and tell me your average response time when one is pressed?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Bethany Home - Brandon | 9.3 mi | Brandon, SD | ★☆☆☆☆ | 1/5 | abuse |
| Dells Nursing and Rehab Center INC | 13.4 mi | Dell Rapids, SD | ★★★★☆ | 4/5 | |
| Good Samaritan Society - Mary Jane Brown | 14.3 mi | Luverne, MN | ★☆☆☆☆ | 2/5 | |
| MN Veterans Home-Luverne | 14.5 mi | Luverne, MN | ★★★★★ | 4/5 | |
| Tuff Memorial Home | 15.0 mi | Hills, MN | ★★★★☆ | 5/5 | |
| Good Samaritan Society Sioux Falls Center | 16.2 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 | abuse |
| Dow Rummel Village | 16.6 mi | Sioux Falls, SD | ★★★☆☆ | 2/5 | |
| Avera Prince of Peace | 17.5 mi | Sioux Falls, SD | ★★★★☆ | 3/5 | |
| Bethany Home Sioux Falls | 18.4 mi | Sioux Falls, SD | ★★★☆☆ | 4/5 | |
| Avantara Norton | 18.5 mi | Sioux Falls, SD | —/5 | abuseSFF | |
| Good Samaritan Society Luther Manor | 18.6 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435115.