Inspection Reports for
Palazzo Post Acute

The facility failed to create and implement an updated care plan for Resident 1 when aggressive behavior was observed and when the resident was readmitted from the hospital, potentially delaying and affecting the quality of care provided.

The complaint investigation substantiated that Resident 2 hit Resident 1 on the jaw on 9/9/2025 at approximately 1 AM after Resident 1 became agitated when not allowed to smoke. Resident 1 experienced pain and required an x-ray. Interviews with residents, staff, and review of records confirmed the incident and inadequate supervision.

The facility failed to protect Resident 1 from physical abuse by Resident 2 and failed to provide adequate supervision to prevent the incident. Resident 1 was hit on the jaw by Resident 2 after Resident 1 became agitated when not allowed to smoke outside designated hours, resulting in jaw pain and requiring an x-ray which showed no fracture.

The facility failed to implement care plan interventions to prevent falls for Resident 1, resulting in Resident 1 sliding off a wheelchair and falling on 2/19/25. The resident sustained no injuries, but the deficiency was noted as minimal harm or potential for actual harm.

The facility was found deficient in multiple areas including failure to ensure residents had legal representatives when cognitively impaired, failure to update care plans after falls, inadequate oral hygiene care, unsafe handling of equipment leading to fall risks, incomplete bowel and bladder assessments, unlabeled feeding tube flush bags, pharmaceutical service deficiencies including missing narcotic emergency kits and incomplete drug disposition documentation, unsafe food storage and sanitation practices, lapses in infection prevention protocols including failure to follow enhanced barrier precautions and aseptic technique, and an insufficient water management plan to control Legionella risks.

The complaint investigation found that Resident 1 was not given the prescribed Benadryl medication on 3/28/25 despite an order from the primary physician following a reported allergic reaction. The facility's Medication Administration Record was not signed, and staff interviews confirmed the medication was not administered.

The facility failed to administer Benadryl 25 mg to Resident 1 as ordered on 3/28/25 when the resident complained of facial itching due to a possible allergic reaction. The Medication Administration Record was not signed to indicate the medication was given, and there was no documentation confirming administration. Interviews with staff and the resident confirmed the medication was not administered.

The facility failed to post the federally required daily actual hours worked by staff for one sampled day (11/12/2024), posting only projected hours. This resulted in actual hours not being readily accessible to residents, family, or visitors.

The complaint investigation found that Resident 1 was not receiving Pomalyst as prescribed. The Director of Nursing confirmed missed medication administration on 5/18/24 and 7/13/24. Licensed Vocational Nurse 2 admitted to not administering the medication on 7/13/24 due to inability to locate it. The pharmacist stated that skipping doses posed a high risk of side effects for Resident 1.

The facility failed to implement a system to consistently and accurately reconcile and administer Pomalyst oral capsules for Resident 1, resulting in the resident missing two dosages on 5/18/24 and 7/13/24. Interviews with staff and review of medication records confirmed the missed doses and identified issues with medication availability and administration.

The complaint investigation was substantiated by interviews with Residents 2 and 7, who reported staff yelling and an argument occurring on the night shift, which compromised their dignity and respect.

The facility failed to ensure dignity and respect for Residents 2 and 7, resulting in potential harm to their self-esteem and self-worth. Interviews revealed staff yelling on the night shift and an argument witnessed by residents, violating the facility's policy on resident rights.

The complaint investigation focused on Resident 74 who experienced frequent loose stools while continuing to receive a laxative. The investigation found the laxative was continued without appropriate intervention or timely physician notification, despite the resident's diarrhea and risk of dehydration. The complaint was substantiated with findings from record reviews and staff interviews.

The facility failed to appropriately manage Resident 74's condition of frequent loose stools by continuing to administer a laxative without timely physician notification or intervention, posing risks of dehydration and other serious complications. Multiple reviews of medical records, medication administration, and staff interviews confirmed the deficient practice and lack of proper communication.

The investigation was complaint-related, focusing on whether the facility properly reviewed transfer records and communicated scheduled appointments. The deficiency was substantiated with findings of missed appointments and delayed treatment.

The facility failed to review Resident 1's hospital transfer records thoroughly and did not notify the physician about multiple scheduled appointments, causing delays in treatment for several dates between 3/18/24 and 4/25/24. Interviews and policy reviews confirmed lapses in admission procedures and communication.

The complaint investigation found that the facility did not follow proper procedures for managing Resident 1's personal funds. The money was kept in the medication cart for two days instead of being transferred to the business office the next business day as required. The Social Services staff and Administrator confirmed the delay and improper handling.

The facility failed to safeguard Resident 1's personal funds when $800 was retrieved by a Licensed Vocational Nurse and stored improperly in the medication cart's narcotic box instead of being placed in the business office the next business day. This posed a potential risk of theft or misuse of the resident's funds.

The complaint involved an alleged verbal abuse incident on 11/14/2023 where CNA 2 reportedly told Resident 1, 'Whoever the person that shot you, did not do a good job.' Resident 1 denied threatening CNA 2 and did not feel affected by the incident. The complaint was reported by CNA 2 to the charge nurse and subsequently to the Director of Nursing. The Social Services Director confirmed the details during an IDT meeting on 11/15/2023.

The facility failed to protect Resident 1 from verbal abuse by CNA 2, who made a hurtful comment during an argument. Resident 1 did not fear remaining in the facility and did not wish to press charges. Interviews with staff and review of records confirmed the incident and the facility's response.

The visit was complaint-related due to Resident 1 eloping from the facility on 6/13/2023. The complaint was substantiated as the facility failed to prevent the resident from leaving unaccompanied. Resident 1 was found the next day at her previous address. Staff interviews revealed alarms were not activated properly, and no receptionist was present at the front desk during the incident.

The facility failed to adequately supervise Resident 1, who left the facility unaccompanied and was found approximately 9 miles away at her previous address. Staff initiated a code green and searched the premises but were unable to locate the resident until the next day. The resident was found in stable condition with no injuries. The facility's wandering and elopement policy was reviewed, and interventions were ordered including a wander guard and hourly monitoring.

The complaint investigation found that the facility did not provide bed hold notices to Resident 1 and Resident 2 upon their transfers to general acute hospitals on 4/21/23 and 4/25/23 respectively. Additionally, Resident 1 was not permitted to return to the facility within the seven-day bed hold period despite being ready to return, resulting in denial of the resident's right to return.

The facility failed to provide written bed hold notices to two residents upon transfer to hospitals and failed to re-admit one resident within the seven-day bed hold period, violating the facility's bed-hold policy and residents' rights.

The complaint was substantiated as CNA 3 was observed and admitted to eating in a resident's room without a face mask, violating facility infection control policies during the COVID-19 crisis.

The facility failed to ensure that CNA 3 adhered to infection prevention and control policies by eating in a resident's room without a face mask, which could lead to the spread of infections including COVID-19. Interviews with CNA 3, the Infection Control Preventionist, and the Administrator confirmed the violation and the potential risk to residents and staff.

The complaint involved an allegation by Resident 1 that LVN 1 grabbed her hands causing bruises. The allegation was not reported by staff or administration to the state survey agency within the required 2-hour timeframe. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to report the allegation of abuse to the state survey agency within the required 2-hour timeframe, resulting in a delay of investigation and failure to protect Resident 1 from further emotional and psychosocial distress. Interviews and observations confirmed bruises on Resident 1's hands and inconsistent reporting among staff.

The complaint investigation substantiated that the Director of Social Services verbally abused Residents 1 and 2 on multiple occasions, resulting in emotional distress and fear. The Social Services Director was terminated on 2/20/2023.

The facility failed to protect residents from verbal abuse by the Director of Social Services, who made inappropriate comments causing psychological distress and fear in Residents 1 and 2. The Social Services Director's employment was discontinued following the investigation.

The facility failed to maintain and document monthly infection surveillance logs to identify infection patterns and outbreaks, and failed to provide written vaccine education materials in Spanish to monolingual Spanish-speaking residents. These deficiencies had the potential to result in disease transmission and deprive residents of informed vaccination decisions.

The visit was complaint-related, triggered by allegations of failure to accommodate resident needs, noise disturbances, inaccurate assessments, failure to follow medical orders, inadequate supervision leading to falls, infection control breaches, and environmental safety issues. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to keep call lights within reach, excessive noise disturbing residents, inaccurate cognitive assessments, failure to follow pain management orders, delayed audiology referrals, inadequate supervision leading to a resident fall and fracture, lack of hands-free sink in rehab room, incomplete documentation of restorative nursing and narcotic administration, improper infection control practices including improper disposal of gowns and failure to wear gloves, and failure to maintain a clean and comfortable environment.

The facility was found deficient in multiple areas including failure to maintain resident privacy during treatment, incomplete care plans for medication and fall risk, delayed discharge summaries, failure to follow up on prescribed vision services, inadequate catheter care and infection control, incomplete staff orientation, inaccurate nurse staffing postings, inappropriate use of psychotropic medications, and serving food that residents found unpalatable and unattractive.