Palisade Healthcare Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

40.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 55 beds and averages 49.0 residents a day — about 89% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.64 hrs/resident/day on weekends vs 3.38 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.63 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 15 most serious are shown; the remaining 14 are one tap away and print in full.

• Immediate jeopardy · J2025-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) complaint intake report review, record review, interview, and policy review, the provider failed to ensure staff provided quality care related to skin injury prevention and skin management processes including completing skin evaluations, accurate communication, accurate documentation, and implementing interventions and treatment orders for one of one sampled resident (1) who developed skin injuries to his left lower leg, left foot, and right lower leg and was hospitalized related to those wounds. Those failures put all residents at potential risk for serious injury or harm. Immediate Jeopardy (IJ) at F684 began on 11/18/25 when the provider failed to evaluate resident 1's left lower leg, left foot, and right lower leg wounds and implement appropriate follow-up procedures. *Administrator A was notified of the IJ on 11/18/25 at 4:03 p.m., and a removal plan was requested.*The IJ was removed on 11/19/25 at 1:00 p.m. as confirmed by onsite verification by the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2026-04-16 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, document review, observation, interview, and policy review, the provider failed to protect the resident's right to be free from neglect for three of three sampled residents (1, 2, and 3) whose incontinence (involuntary urine or bowel leakage) products were not changed timely and the residents were not repositioned per leadership expectations by three of three CNAs (C, E, and P), for one of one sampled resident (4) who reported an unidentified staff member did not change resident 4 for a long period of time and he developed skin irritation and open sores to his perineal area, from abuse for one of one sampled resident (3) whose perineal area (genital area) was cleaned roughly by one of one certified nursing assistant (CNA) (Q) and developed an open sore, from neglect for two of two sampled residents (1 and 5) who requested staff to assist them with care and they did not, and for one of one anonymous resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-09-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and manufacturer's operator's instructions review, the provider failed to ensure:*The safety of one of one sampled resident (1) who fell from a total body lift (a mechanical lift and sling used to lift a person's full body) and sustained a hematoma (an injury that causes a localized collection of blood under the skin) while being transferred by one of one licensed practical nurse (LPN) (C) and one of one certified medication aide/certified nursing assistant (CMA/CNA) (F).*The sling sizes for eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, and 8) who used a total body lift for transfers were assigned according to the sling's manufacturer's instructions. Findings Include:1. Review of the provider's 9/12/25 SD DOH FRI regarding resident 1 revealed:*On 9/12/25 at 11:20 a.m. LPN C and CMA/CNA F had been transferring resident 1 from her wheelchair to her bed.*CMA/CNA F had reported…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-08-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to adequately identify and effectively implement pressure ulcer (skin and/or underlying tissue injury due to prolong pressure) preventative interventions for residents identified at risk for developing pressure ulcers for:*One of one sampled resident (3) who developed a pressure ulcer to her heel.*One of one sampled resident (27) who developed a pressure ulcer to her coccyx (tailbone).Findings include: 1. Observation on 8/5/25 at 9:10 a.m. of resident 3 in her room revealed: *There was a sign on the wall beside the entrance to resident 3’s room that indicated she was on enhanced barrier precautions (personal protective equipment, such as gloves and a gown was to be worn with all close contact resident care). *She was sitting in a wheelchair near her bed. *She was wearing a Prevalon boot (a cushioned boot that floats the heel off the surface of the mattress, to help reduce pressure) on her left foot. *There was a second Prevalon…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to protect one of one (1) resident from neglect due to failure to provide physician-ordered care. Findings include: 1. Review of the provider's SD DOH FRI report submitted on 10/28/24 at 7:27 p.m. revealed: *Resident 1 had a diagnosis of psoriasis (a skin disease that causes a rash and itchy, scaly patches). * On 10/27/24 a family member of resident 1 visited the facility and reported care concerns to another family member. -The room had a foul odor. -The resident's sock was very dirty and saturated. -Maggots were found on his feet. *The family member went to the nurse on duty on 10/27/24 with her concerns. -The nurse sent a certified nursing assistant (CNA) to help clean up the resident. *On 10/28/24 a different family member brought these concerns to administrator A and director of nursing (DON) B: *An assessment of resident 1's legs completed by DON B and the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-16 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview the provider failed to ensure call lights (a communication tool that enabled residents to alert staff for assistance) were within reach for 10 of 10 sampled residents (3, 5, 6, 8, 9, 10, 11, 12, 13, and 14) that would allow the residents to request assistance from staff promptly. Findings included: 1. Observation and interview on 4/14/26 at 9:04 a.m. revealed that resident 9 was slid down in her bed and needed help. Resident 9 stated she did not know where her call light was and never had access to it. Social Services Director (SSD) S entered the room and acknowledged that the call light was hung over the resident's headboard, not within reach of the resident. She moved the call light next to the resident, but thought she could have reached it when it was over the headboard. 2. Observation on 4/14/26 at 9:06 a.m. revealed resident 10 was in bed, and her call light was clipped to its own cord at the wall, not within reach of the resident. SSD S came to the doorway, acknowledged that the call light was not within the resident's reach, and moved it…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-16 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review the provider failed to ensure 1 of 1 resident (7) supra pubic catheter (a tube placed in the bladder to remove urine from the body) was irrigated (flushed) using a sterile graduated cylinder for the saline and vinegar solution that was used to flush her supra pubic catheter by licensed practical nurse (LPN) I.Findings include:1. Observation and interview on 4/16/26 at 9:07 a.m. with licensed practical nurse (LPN) I revealed that resident 7's supra pubic catheter was flushed twice a day. She stated she reused the graduated cylinder, but that she would get a new syringe each time she flushed the catheter. She was trained that way but could not remember who trained her. The cylinder had been written on with a Sharpie, sterile only for vinegar and water, not to empty urine from the catheter. 2. Interview on 4/16/26 at 2:34 p.m. with director of nursing (DON) B revealed she been the at the facility since 4/13/26. She understood that the container should be changed every single time. She was aware that resident 7 has had…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-07 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the provider failed to ensure staff responded timely to residents' call lights for 7 of 18 residents (3, 6, 8, 14, 19, 28, and 54) who expressed complaints regarding staff not responding timely to their call lights to address the residents' needs.Findings include: 1. Observation and interview on 8/5/25 starting at 11:00 a.m. with resident 19 in his room revealed: *At 11:00 a.m. resident 19’s call light was on. *He stated he had turned his call light on about 10:30 a.m. *He stated there were times his call light was on for two hours before it was answered by the staff. *At 11:29 a.m. his call light was answered. Follow-up interview on 8/7/25 at 9:20 a.m. with resident 19 revealed: *At times he had felt like he was going to die by the time his call light was answered. *When he had to wait long periods of time for assistance, he felt degraded. Review of resident 19’s electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 6/23/25 Brief Interview…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-07 · tag F0761 — failed to label and store drugs safely — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and policy review, the provider failed to ensure: *Three of three medication carts were free from medications beyond the use by date after opening for six of six residents sampled. *Two of three shower rooms were free from medications that were intended for individual resident use and without access to staff that were not qualified to administer medications. *Drugs and biologicals are stored according to the facilities policy in two of three shower rooms and one of three medication carts. *Drugs and biologicals are free from access and administration by staff other than trained nurses and certified medication aides (CMAs). Findings include: 1.Observation on 8/6/25 at 2:53 p.m. of the 200 hallway medication cart revealed:*Resident 26s Lantus (long-acting insulin for blood sugar control) insulin pen did not have an open date listed.*Resident 7's Lantus insulin pen and Semglee (long-acting insulin) insulin pen did not have open dates listed on them.*Resident 5's Lispro insulin vial had an open date of 6/28/25 written on it. Review of the facility's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-07 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and policy review, the facility failed to ensure:*The food was appetizing and served at a satisfactory temperature.*Accurate menus were provided to residents.Findings include: 1. Interview on 8/5/26 at 9:06 a.m. with resident 2 revealed: *She stated the facility’s food service was fair to poor and unorganized. *If she did not like the food being served her alternate meal option was soup and a sandwich. *She felt it took a long time for her to be served her meal in the dining room. *She thought her table was always the last table to be served and by the time she received her meal the food was cold. 2. Interview on 8/5/25 at 10:58 a.m. with resident 18 revealed: *He ate all of his meals in his room. *He did not like the food he was served. *When he received his food, it was cold at times. *Staff used to bring a menu to his room, so he knew what was being served but that no longer happened. *He stated he would need to go down to the dining room to see what was on the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-07 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow infection prevention and control processes to ensure:*Proper hand hygiene, glove use, and gown use, was performed by eight of eight observed staff members (certified nursing assistant (CNA) R, K, L, and O, licensed practical nurse (LPN) I, housekeeper Z, and registered nurse (RN) H) during resident care for four of four sampled residents (1, 3, 5 and 27). *Contact precaution protocols were followed by one of one observed LPN (C) during resident care activities and medication administration for one of one sampled resident (52) related to an infectious bacterial infection in her stool.*The mechanical lift was cleaned between resident use by four of four observed staff members (CNAs L, O, and P, and LPN N) during two of three missed opportunities. 1.Observation on 8/5/25 at 10:24 a.m. of RN H and LPN I while providing resident 1‘s wound care revealed: *RN H and LPN I performed hand hygiene then put on a pair of gloves…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure the Medicare notice given to the resident and/or the representative was:*Provided on the current form and completed according to the form's instructions for one of two sampled resident (1) who had discharged from Medicare skilled part A services and remained in the facility.*Completed according to the form's instructions for one of two sampled resident (22) who had discharged from Medicare part A services and remained in the facility.Findings include:1. Review of the Entrance Conference Worksheet completed by the provider on 8/6/25 revealed that two sampled residents (1 and 22) had been discharged from Medicare Part A skilled services and remained in the facility. 2. Review of the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123, with a revision date of July 2022, for resident 1 revealed: *His last covered day on Medicare Part A Skilled Service was 4/4/25. *The required information of You have the right to get your information in an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and policy review, the provider failed to report an allegation of suspected neglect for one of one sampled resident (56). This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident. Findings include:1.Review of the provider's 4/10/25 SD DOH FRI revealed:*On 4/3/25 certified nursing assistant (CNA)/certified medication aide (CMA)/activities director J reported via a grievance form that resident 56's incontinence product had not been changed on the night shift.*Resident 56 was noted to be very incontinent of urine.*Resident 56's diagnoses included: -Dementia (a group of symptoms affecting memory, thinking, and social abilities).-Congestive heart failure (heart does not pump blood as well as it should).-Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe).-Agitation (feeling of restlessness or nervous excitement).*Resident 56 was receiving…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2025-03-12 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review the provider failed to ensure one of one sampled resident's (1) care plan had been updated to reflect his current needs regarding the fall intervention for his use of a wheelchair with an anti-rollback bracket (to prevent it from rolling backward) as indicated in the provider's SD DOH FRI following the residents fall on 1/17/25 when he sustained a head laceration that required evaluation and stitches at a hospital. Findings include: 1. Review of the provider's SD DOH facility online report revealed: *On 1/17/25 Resident 1 had been sitting in his wheelchair in the common area near the nurses' station watching television. -The nurse heard a crash and resident 1 yelled. -The nurse noted resident 1 had tipped forward in his wheelchair and hit his head on the floor. -Resident 1 was assessed and had a laceration to his left eyebrow that needed repair and the resident was sent to the hospital. -Resident 1 was able to ambulate short distances with staff. -He used the wheelchair…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review and policy review, the provider failed to ensure one of one resident (1) had an antiroll back bracket on his wheelchair to prevent it from rolling backwards when he attempted to stand up and self-transfer after he fell on 1/17/25 sustaining a laceration to his head and going to the hospital for sutures to that area. Findings include: 1.Review of the provider's SD DOH facility online report revealed: *On 1/17/25 Resident 1 had been sitting in his wheelchair in the common area near the nurses' station watching television. -The nurse heard a crash and resident 1 yelled. -The nurse noted resident 1 had tipped forward in his wheelchair and hit his head on the floor. -Resident 1 was assessed and had a laceration to his left eyebrow that needed repair and the resident was sent to the hospital. -Resident 1 was able to ambulate short distances with staff. -He used the wheelchair for locomotion and was able to propel himself in the wheelchair or staff would propel him…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$154,946 in federal fines across 4 penalties.

• $122,476 — penalty dated 2025-11-19
• $8,608 — penalty dated 2025-09-17
• $11,713 — penalty dated 2025-08-07
• $12,149 — penalty dated 2024-11-26

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 34 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $101K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD