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
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing
LPN hours / resident day
0.81
Licensed practical nurse staffing
Aide hours / resident day
2.21
Nurse aide staffing
Weekend hours
2.98
Weekend nurse staffing
RN turnover
17%
Annual RN turnover
Total nurse turnover
59%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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
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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
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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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