Palisade Healthcare Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
called and faxed the wound care clinic that day (10/22/25), but never heard back, and felt she did not work at the facility often enough to follow up on that. 14. Interview on 11/19/25 at 10:53 a.m. with resident 1's son revealed:*He visited his father on 10/18/25 and left early on 10/22/25, so he had not seen him that day. *When he arrived, his father's left ankle was wrapped up, and there were visible red areas on the skin of his legs.*He notified the nurse, who told him they were monitoring it and planned to move up his wound care appointment. *The wound clinic called him on 11/4/25, informing him that resident 1's wounds were a potential amputation situation. *The vascular surgeon, had taken care of his father for years, informed him that if the facility had acted sooner, the situation could have been corrected. 15. Review of the provider's updated July 2025 Skin Integrity policy revealed:* In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds, the facility has a systemic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds.* The resident's skin is inspected daily with completion of ADL's [activities of daily living] (unless [the] resident is independent in ADL completion).
Changes in the resident's skin are reported to the Licensed Nurse (LN).* Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the treatment administration record (TAR) with their initials.* If skin impairment is noted after admission (in addition to the above steps), the LN:a. Initiates alert charting.b. Completes (and documents) notifications to
the medical provider and resident or resident representative.c. Implements new interventions as needed.
Documents on the resident's care plan. d. Notified Food and Nutrition Services Manager (FANS) and/or Registered Dietitian of new pressure injury or worsening wound condition for nutritional needs evaluation.e.
Notifies Director of Nursing Services (DNS) of skin impairments that indicate a potential significant change
in condition (Stage II or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on an area of the body not usually vulnerable to trauma (e.g. head, breasts, inner thighs, groin). f. The DNS and/or designee complete a comprehensive review of the resident's medical record to evaluate if the pressure injury was avoidable or unavoidable. This evaluation is documented in the nurse's notes.
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PALISADE HEALTHCARE CENTER in GARRETSON, SD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GARRETSON, SD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PALISADE HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.