Palisade Healthcare Center

In the surveyor’s words

From the most serious findings on record at Palisade Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 19, 2025

  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. […]

• Actual harm, patternF600Apr 16, 2026

  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… […]

• Actual harm, patternF584Aug 25, 2021

  A. Based on observation, interview, record review, testing, resident group meeting interview, and policy review, the provider failed to maintain a comfortable room temperature for fifteen random residents (1, 7, 8, 10, 11, 12, 13, 15, 17, 21, 24, 25, 35, 36, and 37) Findings include: Surveyor: 1. Review of the resident council minutes on: *4/5/21 documentation for maintenance/housekeeping/laundry department A/C's [air conditioners] in rooms. *5/10/21 documentation for maintenance/housekeeping/laundry department No window AC's. *6/25/21 documentation for other No air conditioning - explained doors open, air comes thru [through] halls - if windows open, then doors need to be shut. *7/12/21 documentation for maintenance Discussed air conditioning protocol thru out [throughout] the building. […]

• Actual harm, patternF678Aug 25, 2021

  Based on observation, interview, record review, and policy review, the provider failed to ensure the following: *One of one resident (30) who was of full code status received interventions to prevent his death. *Residents who were cognitively impaired understood what their code status entailed. *Registered nurse (RN) E was aware of which residents were full code and where the crash cart was located. *Code status book was updated with the most current code statuses of residents. Findings include: 1. Observation and interview on [DATE] at 9:09 a.m. RN E revealed: *She was the nurse in charge of the 100 and 200 hallway, that day. *Surveyor asked which residents were full code status. -She said she knew of one for sure. *They kept the code status' in the nurses station in a book. […]

• Actual harm, isolatedF689Sep 17, 2025

  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. […]