Palisade Healthcare Center
920 4TH ST, Garretson, SD, 57030
Yes. Federal inspectors cited 12 deficiencies against Palisade Healthcare Center in Garretson, South Dakota at its most recent standard inspection on 2025-08-07, 6 of them arising from complaints. 1 finding has been recorded at the immediate-jeopardy level, the most serious CMS uses, meaning a resident was placed in immediate danger. Medicare has fined it 4 times, totalling $154,946. CMS currently flags this home for abuse. Medicare rates it 1 out of 5 overall.
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
The last 20 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0600 · 2026-04-16 · from a complaint · Actual harm to a resident
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · F0919 · 2026-04-16 · from a complaint · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2026-04-16 · from a complaint · No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · F0684 · 2025-11-19 · from a complaint · Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2025-09-17 · from a complaint · Actual harm to a resident
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · F0686 · 2025-08-07 · standard survey · Actual harm to a resident
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · F0725 · 2025-08-07 · standard survey · No actual harm, potential for more than minimal harm
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.
Pharmacy Service Deficiencies · F0761 · 2025-08-07 · standard survey · No actual harm, potential for more than minimal harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · F0804 · 2025-08-07 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2025-08-07 · standard survey · No actual harm, potential for more than minimal harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · F0582 · 2025-08-07 · standard survey · No actual harm, potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0609 · 2025-08-07 · from a complaint · No actual harm, potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · F0657 · 2025-03-12 · from a complaint · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2025-03-12 · from a complaint · No actual harm, potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0600 · 2024-11-26 · from a complaint · Actual harm to a resident
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · F0657 · 2024-11-26 · from a complaint · No actual harm, potential for more than minimal harm
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · F0760 · 2024-08-07 · from a complaint · No actual harm, potential for more than minimal harm
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.
Resident Rights Deficiencies · F0584 · 2024-03-18 · standard survey · No actual harm, potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · F0812 · 2024-03-18 · standard survey · No actual harm, potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · F0695 · 2024-03-18 · standard survey · No actual harm, potential for more than minimal harm
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
What Medicare has fined this home
Who owns Palisade Healthcare Center
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS (SD) LLC | Organization | 100% | since 08/31/2023 |
| CHEEKS, DONALD | Individual | NOT APPLICABLE | since 08/31/2023 |
| EVANS, KAYLA | Individual | NOT APPLICABLE | since 08/31/2023 |
| SPIELMAN, SHIMON | Individual | NOT APPLICABLE | since 08/31/2023 |
| YENOWITZ, YITZCHOK | Individual | NOT APPLICABLE | since 08/31/2023 |
| COUVE FINANCIAL SERVICES LLC | Organization | NOT APPLICABLE | since 08/31/2023 |
| COUVE HEALTHCARE CONSULTING LLC | Organization | NOT APPLICABLE | since 08/31/2023 |
| PACIFIC NORTHWEST OPCO MANAGEMENT LLC | Organization | NOT APPLICABLE | since 08/31/2023 |
| PALISADE SNF OPERATIONS, LLC | Organization | NOT APPLICABLE | since 08/31/2023 |
| SOUTH DAKOTA SNF CONSULTING LLC | Organization | NOT APPLICABLE | since 08/31/2023 |
| CHEEKS, DONALD | Individual | NOT APPLICABLE | since 08/31/2023 |
| EVANS, KAYLA | Individual | NOT APPLICABLE | since 08/31/2023 |
Part of the EVERGREEN HEALTHCARE GROUP group.
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 435115.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction