920 4th St, Garretson, SD 57030 (opens Google Maps) · Minnehaha County · (605) 594-3466· 55 certified beds · avg 49 residents/day · certified since Oct 1, 1998 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
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.
New to these records? How to read an inspection report →
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →
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 quality measures from resident assessments and claims.
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, pattern · 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): Actual harm was cited, below immediate jeopardy. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 6, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Sep 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Aug 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Dec 16, 2024 (Deficient, Provider has date of correction)
Showing the latest 3 of 29 inspection findings. Open the full record below to read every finding.
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 F-0600
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 F-0919
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 F-0880
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 16, 2026 | ▲ H · Actual harm, pattern | 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 · F-0600 |
| Apr 16, 2026 | E · Potential for more than minimal harm, pattern | 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 · F-0919 |
| Apr 16, 2026 | D · Potential for more than minimal harm, isolated | 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 · F-0880 |
| Nov 19, 2025 | ▲ J · Immediate jeopardy, isolated | 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 · F-0684 |
| Sep 17, 2025 | ▲ G · Actual harm, isolated | 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 · F-0689 |
| Aug 7, 2025 | ▲ G · Actual harm, isolated | 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. · F-0686 |
| Aug 7, 2025 | E · Potential for more than minimal harm, pattern | 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. · F-0725 |
| Aug 7, 2025 | E · Potential for more than minimal harm, pattern | 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. · F-0761 |
| Aug 7, 2025 | E · Potential for more than minimal harm, pattern | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804 |
| Aug 7, 2025 | E · Potential for more than minimal harm, pattern | 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. · F-0880 |
| Aug 7, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0582 |
| Aug 7, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0609 |
| Mar 12, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0657 |
| Mar 12, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0689 |
| Nov 26, 2024 | ▲ G · Actual harm, isolated | 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 · F-0600 |
| Nov 26, 2024 | D · Potential for more than minimal harm, isolated | 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 · F-0657 |
| Aug 7, 2024 | D · Potential for more than minimal harm, isolated | 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 · F-0760 |
| Mar 18, 2024 | F · Potential for more than minimal harm, widespread | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584 |
| Mar 18, 2024 | F · Potential for more than minimal harm, widespread | 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. · F-0812 |
| Mar 18, 2024 | E · Potential for more than minimal harm, pattern | 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. · F-0695 |
| Mar 18, 2024 | E · Potential for more than minimal harm, pattern | 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. · F-0880 |
| Mar 18, 2024 | D · Potential for more than minimal harm, isolated | 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. · F-0550 |
| Mar 18, 2024 | D · Potential for more than minimal harm, isolated | 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. · F-0578 |
| Mar 18, 2024 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| Mar 18, 2024 | D · Potential for more than minimal harm, isolated | 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. · F-0909 |
| Dec 28, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0658 |
| Mar 8, 2023 | E · Potential for more than minimal harm, pattern | 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. · F-0657 |
| Mar 8, 2023 | E · Potential for more than minimal harm, pattern | 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. · F-0678 |
| Mar 8, 2023 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 6).
All bars start at zero. Exact values and supporting details remain below.
| 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.
How to file a complaint about care →
4 fines totaling $154,946.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| 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 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| 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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.16 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Palisade Healthcare Center. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
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 |
Showing 20 of 34 parties CMS has on file for this facility; 14 are not displayed. The full list is in the CMS Ownership dataset.
CMS lists this facility under the chain Evergreen Healthcare Group — 44 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Listed by state, then facility name — not a ranking. Showing 8 of the 43 others, continuing from this facility's own place in that list.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| 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 |
Facility data as of CMS processing date 2026-08-01. CCN 435115.
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