Palisade Healthcare: Immediate Jeopardy Cited - SD
The case at Palisade Healthcare Center prompted federal inspectors to issue an immediate jeopardy citation on November 19, finding the facility failed to ensure residents received necessary care and services to attain their highest possible level of well-being.
Resident 1's son visited his father on October 18 and found his left ankle wrapped with visible red areas on the skin of his legs. When he alerted nursing staff, they told him they were monitoring the condition and planned to move up his wound care appointment.
The son left early on October 22 and did not see his father that day. What he didn't know was that a nurse had called and faxed the wound care clinic that same day but never received a response. The nurse later told inspectors she felt she did not work at the facility often enough to follow up on the referral.
Two weeks passed with no further action.
On November 4, the wound clinic finally called the resident's son with devastating news: his father's wounds had become a potential amputation situation. The vascular surgeon, who had treated the resident for years, delivered a stark assessment - if the facility had acted sooner, the situation could have been corrected.
The delay violated the facility's own policies for wound care. According to Palisade Healthcare's updated skin integrity policy from July 2025, staff must inspect residents' skin daily and report changes to licensed nurses. Licensed nurses must complete weekly full-body skin audits and take immediate action when skin impairment develops after admission.
The policy requires nurses to initiate alert charting, notify medical providers and family members, implement new interventions, update care plans, and inform dietary staff of wound conditions that might require nutritional evaluation. For significant changes like Stage II pressure ulcers or surgical wound problems, nurses must notify the Director of Nursing Services.
Most critically, the policy mandates that the nursing director conduct a comprehensive medical record review to determine if pressure injuries were avoidable or unavoidable - documentation that must appear in nursing notes.
None of these systematic protections prevented the breakdown in this resident's care.
The inspection revealed a facility with written protocols that promised comprehensive wound monitoring but failed to execute basic follow-through. A single phone call and fax to a wound clinic went unanswered, and no one ensured the resident received the specialized care that could have prevented a potential amputation.
The nurse's admission that she didn't work at the facility often enough to follow up highlights a staffing pattern that left critical medical decisions in the hands of personnel who couldn't provide continuity of care. When wound care clinics don't respond, someone must persist. When red areas appear on a resident's legs, someone must ensure prompt evaluation.
The resident's son trusted that his father would receive appropriate medical attention when he reported the concerning skin changes. Instead, his father's condition deteriorated while staff failed to pursue the referral they had initiated.
By the time specialists finally evaluated the resident's wounds, the damage was extensive enough that amputation became a possibility. The vascular surgeon's assessment that earlier action could have corrected the situation underscores the human cost of the facility's failure to follow through on basic medical care.
The case demonstrates how administrative breakdowns translate into irreversible harm for nursing home residents. A missed follow-up call, an unreturned fax, and insufficient staffing continuity combined to create a cascade of neglect that may cost a resident his limb.
Federal inspectors found the facility's failure to ensure necessary care and services placed residents in immediate jeopardy. For one family, that regulatory language represents the difference between their father keeping his leg and facing amputation because no one made a second phone call.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palisade Healthcare Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PALISADE HEALTHCARE CENTER in GARRETSON, SD was cited for immediate jeopardy violations during a health inspection on November 19, 2025.
Resident 1's son visited his father on October 18 and found his left ankle wrapped with visible red areas on the skin of his legs.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.