Cycle 1
Health 2025-08-07 · Fire 2025-08-07
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Garretson, SD
Palisade Healthcare Center
1-star overall rating with 1-star inspections with $235,809 in total fines with 11 recent health deficiencies
920 4th St, Garretson, SD
(605) 594-3466
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1998-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,625
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.96
Baseline 18.62% · Performance 17.74% · Measure score 7.96 · Achievement 7.96 · Improvement 5.03
Healthcare-associated infections
2.62
Baseline 6.49% · Performance 7.05% · Measure score 2.62 · Achievement 2.62 · Improvement 0
Total nurse turnover
0
Baseline 59.46% · Performance 68.18% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.31
Baseline 3.25 hours · Performance 3.74 hours · Measure score 2.31 · Achievement 2.31 · Improvement 1.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.76% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 16.83% · Lower 95% interval 8.44% |
| Discharge to community | 39.99% |
50.57%
10.6 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 27.5% · Lower 95% interval 27.99% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90.77% |
95.27%
4.5 pts worse
|
Numerator 59 · Denominator 65 |
| Falls with major injury | 3.08% |
0.77%
2.3 pts worse
|
Numerator 2 · Denominator 65 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 16 · Denominator 48 |
| Discharge mobility score | 22.92% |
50.94%
28 pts worse
|
Numerator 11 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 4.62% |
2.29%
2.3 pts worse
|
Numerator 3 · Denominator 65 · Adjusted rate 3.89% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 9.26% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 51 |
| Staff flu vaccination coverage | 56.98% |
42%
15 pts better
|
Numerator 49 · Denominator 86 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 20 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.57% |
25.2%
23.4 pts better
|
Numerator 17 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
1.5
2.1 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 4.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.9
0.1 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.4%
4.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
5.1%
0.5 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 6.4% · Q3 4.5% · Q4 0.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
4.6%
1.8 pts worse
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 7.7% · Q4 12.8% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.5%
3.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.7% · Q3 0.0% · Q4 3.2% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
17.8%
5.9 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 13.5% · Q3 8.3% · Q4 11.8% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
25.1%
9.7 pts better
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.2% · Q3 7.1% · Q4 17.9% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.4% |
21.3%
5.9 pts better
|
16.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 18.6% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
21.6%
18 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.9% · Q3 2.9% · Q4 3.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.0%
1.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
3.3%
1 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.1% · Q3 2.3% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
25.8%
0.8 pts better
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 21.6% · Q3 30.4% · Q4 30.1% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.6%
0.5 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.3% · Q3 4.2% · Q4 5.6% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
83.2%
8.8 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 86.0% · Q3 91.7% · Q4 97.9% · 4Q avg 92.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.7%
4.2 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.4% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.1% |
78.2%
0.9 pts better
|
79.7%
0.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
21.5%
0.2 pts worse
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 22.2% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-18 · Fire 2024-03-18
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-08 · Fire 2023-03-08
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-03-18
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-03-18
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-03-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-18
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-04-11
E · Potential for more than minimal harm
2023-03-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-28
E · Potential for more than minimal harm
2023-03-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-27
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-20
G · Actual harm
2025-09-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-18
G · Actual harm
2025-08-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-08-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-08-07
F761 · Pharmacy Service Deficiencies
Health
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 2025-08-22
E · Potential for more than minimal harm
2025-08-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-28
G · Actual harm
2024-11-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-08-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-03-18
F584 · Resident Rights Deficiencies
Health
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 2024-04-11
F · Potential for more than minimal harm
2024-03-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-11
E · Potential for more than minimal harm
2024-03-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-11
E · Potential for more than minimal harm
2024-03-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-18
F578 · Resident Rights Deficiencies
Health
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 2024-04-11
D · Potential for more than minimal harm
2024-03-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-18
F909 · Environmental Deficiencies
Health
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 2024-04-11
D · Potential for more than minimal harm
2023-12-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-03-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-08
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$188,425
2025-11-19
Fine
Fine · fine $188,425
Fine
$17,215
2025-09-17
Fine
Fine · fine $17,215
Fine
$18,020
2025-08-07
Fine
Fine · fine $18,020
Fine
$12,149
2024-11-26
Fine
Fine · fine $12,149
Fine
Ownership
Pacific Northwest SNF Operations Holdings (Sd) LLC
5% Or Greater Direct Ownership Interest · Organization
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Cheeks, Donald
Operational/Managerial Control · Individual
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Evans, Kayla
Operational/Managerial Control · Individual
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Pacific Northwest SNF Operations Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Palisade SNF Operations, LLC
Operational/Managerial Control · Organization
Parker, Lourdes
Operational/Managerial Control · Individual
Perlman, Harold
Operational/Managerial Control · Individual
Rees, Joseph
Operational/Managerial Control · Individual
Roby, Brittney
Operational/Managerial Control · Individual
South Dakota SNF Consulting LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Spielman, Shimon
Corporate Officer · Individual
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Yenowitz, Yitzchok
5% Or Greater Indirect Ownership Interest · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Bethany Home - Brandon
Brandon, SD
1-star overall rating with 1-star inspections with $24,385 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Dells Nursing And Rehab Center Inc
Dell Rapids, SD
4-star overall rating with 4-star inspections with $176,155 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Mary Jane Brown
Luverne, MN
1-star overall rating with 2-star inspections with $62,045 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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