Palisade Healthcare Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 31 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Above-median deficiencies (11 vs median 5.0)
- High staff turnover (59%)
Bottom 25% in SD · Below recommended RN staffing · Worst in EVERGREEN HEALTHCARE GROUP chain · $235,809 in fines
What this means for your family
While the rehab therapy team receives praise for helping residents regain strength, the recurring reports of unaddressed falls and poor communication from management are critical red flags. If you choose this facility, ensure you have a clear, documented plan for how the facility will notify you of any health changes, and consider frequent, unannounced visits to monitor your loved one's care.
Google Reviews
Google Reviews
31 reviews on Google“Palisade Healthcare Center receives highly polarized feedback, with some families praising the compassionate staff and effective rehab therapy, while others report severe incidents of neglect and poor communication. Multiple reviewers have raised alarming concerns regarding resident falls, delayed medical intervention, and a lack of responsiveness from management during health crises. Families considering this facility should be aware of the significant discrepancy between the positive experiences of some and the reports of safety failures from others.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and friendly floor nursing staff
- Effective physical and occupational therapy department
- Clean and well-maintained environment
- Helpful social work and administrative support for some families
Concerns
- Negligence regarding resident falls and delayed medical response (mentioned by 5 reviewers)
- Poor communication from management and nursing leadership (mentioned by 4 reviewers)
- Inadequate basic care including hygiene and feeding (mentioned by 3 reviewers)
- Understaffing issues (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 36 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1Given the recent focus on improving communication, what is the best way for our family to stay updated on our loved one's daily health status and care plan?
- 2I noticed the facility has had some recent challenges with medical response times; what specific protocols are in place to ensure residents receive immediate attention if a fall or health emergency occurs?
- 3The physical and occupational therapy departments are highly regarded here; how do you integrate those services into the daily routine for residents who need extra support with mobility or hygiene?
- 4I see that management is active in responding to feedback online; how does that leadership team translate that responsiveness into daily improvements for resident care and dining experiences?
- 5With a smaller community of 55 residents, what kind of social activities or engagement programs do you offer to ensure residents feel connected and active throughout the week?
- 6What steps is the facility taking to ensure that staffing levels remain consistent, particularly during shift changes, to maintain the high standard of care your nursing team is known for?
Personalized based on this facility's data
Key Review Excerpts
“My mom was in this facility for 2 weeks and it was by far the worst experience, My mom ended up in the hospital after falling from her bed with a concussion and a fracture on her spine and several other injuries, she was not taking care of.”
“The Therapy Department is great. Only small complaints would be the food is Novery good, and some of the equipment is very old, and outdated, and should be replaced.”
“Transport at noon arrival... 3 hours later she fell ...called me only cuts on hand... arrived at noon next day ...PT was present for right arm ...she was not able to lift left arm or bend elbow.... heavily medicated unable to stand”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
13
measures
1
measures
3
measures
Residents needing more daily help over time
Residents whose walking got worse
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents vaccinated for the flu
Residents whose bladder or bowel control got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed multiple complaint reports leading to deficiencies in resident safety, care planning, and medication management. The facility shows recurring issues with accident prevention appearing across multiple surveys, care plan development cited repeatedly, and medication errors. While all deficiencies have correction dates, the pattern of ongoing complaints and repeated violations in core safety areas suggests persistent quality concerns families should carefully evaluate.
Apr 16, 2026Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Nov 19, 2025Complaint1
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Sep 17, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Aug 7, 2025Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Aug 7, 2025Routine6
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Mar 12, 2025Complaint2
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Federal Penalties
Fine
Nov 19, 2025
$122,476
Fine
Sep 17, 2025
$8,608
Fine
Aug 7, 2025
$11,713
Fine
Nov 26, 2024
$12,149
Ownership & Operations
Who Operates This Facility
Palisade Healthcare Center
for profit
Chain Affiliation
Evergreen Healthcare Group
43 facilities nationwide
Chain avg rating: 2.3/5 · Rank 38 of 41 (Worst)
Ownership & Management
Owners
Pacific Northwest Snf Operations Holdings (sd) LLC
Owner · Organization
Yenowitz, Yitzchok
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
31 reviews from families & visitors
Official Website
Visit palisadecare.com
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.