Palisade Healthcare: Resident Harm From Hazards - SD
Federal inspectors cited Palisade Healthcare Center following a September 2025 complaint inspection, assigning the violation the agency's "actual harm" designation, meaning inspectors concluded residents were hurt, not merely placed at risk.
The citation centered on the facility's use of the EZWay Safety Program, a patient lift system that sizes slings based on a resident's hip width, chest width, and seated height from the bone to the top of the head. The system offers five children's sizes and nine additional sizes ranging from extra small to 5XL. Weight is not factored into the sizing calculation.
At some point before the inspection, the facility had introduced equipment from a different manufacturer into that system. On September 16, 2025, one day before inspectors arrived, administrator A received an email from the EZWay Safety Program Coordinator making the company's position clear: "If an item is purchased to be used with another brand product, EZWay will not be held liable for any issues resulting from usage with non-EZWay equipment."
The facility's own job descriptions described the chain of responsibility for exactly this kind of situation. Charge nurses were responsible for evaluating resident care against individual needs and physician plans. Certified nursing assistants worked under their supervision and were expected to follow established long-term care standards. The inspection record does not indicate that either layer of that oversight caught the equipment mismatch before harm occurred.
Inspectors noted the violation affected a small number of residents. The inspection report does not describe the specific injuries those residents sustained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palisade Healthcare Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
PALISADE HEALTHCARE CENTER in GARRETSON, SD was cited for violations during a health inspection on September 17, 2025.
The system offers five children's sizes and nine additional sizes ranging from extra small to 5XL.
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.