Federal inspection record · CMS data as of October 1, 2026
Palisade Healthcare Center
920 4th St, Garretson, SD · (605) 594-3466
- Cited for abuse (CMS abuse icon)
- Special Focus Facility
- Certified beds
- 55
- Residents per day
- 49
- Ownership
- For-Profit
- Chain
- Evergreen Healthcare Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- October 1, 1998
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in South Dakota.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among South Dakota homes
Palisade Healthcare Center carries 170.25 inspection points. That is fewer than 3% of South Dakota's 94 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in South Dakota: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–14 pts
- 4★ 14–31.5 pts
- 3★ 31.5–55 pts
- 2★ 55–95.25 pts
- 1★ over 95.25 pts
Bars show every rated home in South Dakota by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
29 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (5)
-
H
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Resident Assessment and Care Planning6E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Rights4F
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- F
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.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
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.
Infection Control3E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Quality of Life and Care3E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Environmental2E
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
- D
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.
Pharmacy Service2E
- E
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.
- D
Ensure that residents are free from significant medication errors.
Nutrition and Dietary2F
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nursing and Physician Services1E
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspection history
2025-08-07
10 health deficiencies · 0 fire-safety deficiencies
Top issue: Infection Control (2 deficiencies)
2024-03-18
14 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2023-03-08
5 health deficiencies · 2 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 30 min of nursing staff time a day, 36 min of it from a registered nurse.
This home
3 h 30 min
South Dakota average
3 h 51 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 64% of nursing staff and 50% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$249,546 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-04-16 | Fine | $94,600 |
| 2025-11-19 | Fine | $122,476 |
| 2025-09-17 | Fine | $8,608 |
| 2025-08-07 | Fine | $11,713 |
| 2024-11-26 | Fine | $12,149 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.2 pts worse | 2.7 | 1.5 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.4 pts better | 1.3 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine5.1 pts better | 100.0% | 94.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.8 pts better | 100.0% | 97.2% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury4.9 pts better | 0.6% | 5.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms3 pts worse | 8.9% | 5.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.5 pts better | 2.2% | 5.7% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication4.7 pts better | 13.0% | 17.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication14.6 pts better | 10.2% | 24.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened10.5 pts better | 7.8% | 18.3% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased15.8 pts better | 5.7% | 21.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.6 pts better | 0.3% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.9 pts better | 0.0% | 2.9% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2.6 pts worse | 27.1% | 24.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers4.5 pts worse | 9.0% | 4.5% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine14.9 pts better | 98.8% | 83.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit5.5 pts better | 7.8% | 13.3% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication2.2 pts better | 0.0% | 2.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine22.1 pts better | 97.6% | 75.5% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.9 pts worse | 21.9% | 20.0% | 23.4% |
·
Who owns and runs it
34 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Pacific Northwest SNF Operations Holdings (Sd) LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 6 facilities |
| Ch Pacific Northwest Holdings LLC | Adp Of The SNF · Organization | 0% | 22 facilities |
| Cheeks, Donald | Managing Control - Governing Body · Individual | 0% | 7 facilities |
| Cheeks, Donald | Operational/Managerial Control · Individual | 0% | 7 facilities |
| Cheeks, Donald | Adp Of The SNF · Individual | 0% | 7 facilities |
| Couve Financial Services LLC | Operational/Managerial Control · Organization | 0% | 41 facilities |
| Couve Financial Services LLC | Adp Of The SNF · Organization | 0% | 41 facilities |
| Couve Healthcare Consulting LLC | Operational/Managerial Control · Organization | 0% | 50 facilities |
| Couve Healthcare Consulting LLC | Adp Of The SNF · Organization | 0% | 50 facilities |
| Evans, Kayla | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Evans, Kayla | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Evans, Kayla | Adp Of The SNF · Individual | 0% | 2 facilities |
| Herzka, Yisroel | Adp Of The SNF · Individual | 0% | 75 facilities |
| Pacific Northwest Opco Management LLC | Operational/Managerial Control · Organization | 0% | 29 facilities |
| Pacific Northwest Opco Management LLC | Adp Of The SNF · Organization | 0% | 29 facilities |
| Palisade SNF Operations, LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Palisade SNF Operations, LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Palisade SNF Realty LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Parker, Lourdes | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Parker, Lourdes | Adp Of The SNF · Individual | 0% | 1 facilities |
| Rees, Joseph | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Rees, Joseph | Adp Of The SNF · Individual | 0% | 4 facilities |
| Roby, Brittney | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Roby, Brittney | Adp Of The SNF · Individual | 0% | 1 facilities |
| South Dakota SNF Consulting LLC | Operational/Managerial Control · Organization | 0% | 6 facilities |
| South Dakota SNF Consulting LLC | Adp Of The SNF · Organization | 0% | 6 facilities |
| Spielman, Shimon | Corporate Officer · Individual | 0% | 48 facilities |
| Spielman, Shimon | Operational/Managerial Control · Individual | 0% | 48 facilities |
| Spielman, Shimon | Adp Of The SNF · Individual | 0% | 48 facilities |
| Witzcorp Global LLC | Adp Of The SNF · Organization | 0% | 21 facilities |
| Yenowitz, Yitzchok | Corporate Officer · Individual | 0% | 50 facilities |
| Yenowitz, Yitzchok | Operational/Managerial Control · Individual | 0% | 50 facilities |
| Yenowitz, Yitzchok | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 50 facilities |
| Yenowitz, Yitzchok | Adp Of The SNF · Individual | 0% | 50 facilities |
·
Fire safety
8 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke5E
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Install an approved automatic sprinkler system.
- D
Install corridor and hallway doors that block smoke.
- E
Provide properly protected cooking facilities.
- E
Inspect, test, and maintain automatic sprinkler systems.
Construction1D
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
Egress1D
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Services1D
- D
Have an externally vented heating system.
·
Other homes nearby
-
Bethany Home - Brandon
Brandon, SD · Abuse icon
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 4 h 48 min
- Fines
- $61,978
-
Dells Nursing And Rehab Center Inc
Dell Rapids, SD
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 2 h 58 min
- Fines
- $173,010
-
Good Samaritan Society - Mary Jane Brown
Luverne, MN · Good Samaritan Society
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 54 min
- Fines
- $57,045