Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Arizona average
Arizona average: 3.7 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
105% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
No deficiencies were found during the on-site compliance inspection and investigation of complaint 00143378.
Complaint Details
Complaint 00143378
Findings
No deficiencies were found during the on-site compliance inspection and investigation of complaint 00143378.
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 0
Date: Jul 23, 2025
Visit Reason
No deficiencies were found during the on-site investigation of complaint 00104620.
Complaint Details
Complaint 00104620
Findings
No deficiencies were found during the on-site investigation of complaint 00104620.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to investigate complaints related to timely reporting of suspected abuse or misappropriation, quality of nursing services, and adherence to physician orders following an unwitnessed fall.
Complaint Details
The complaint investigation focused on allegations that the facility did not report misappropriation of resident property within 24 hours, failed to meet professional standards in continence and shower care, and did not timely address physician orders following a resident's unwitnessed fall. The misappropriation report was submitted late, continence care documentation was incomplete, and diagnostic testing was delayed resulting in delayed hospital transfer. Family notification was also inadequate.
Findings
The facility failed to timely report an allegation of misappropriation within the required 24-hour timeframe, failed to provide continence and shower care according to professional standards for one resident, and failed to ensure weekly skin assessments and timely diagnostic testing following a fall. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or theft within the mandated 24-hour timeframe.
Failure to provide continence and shower care according to professional standards, risking skin breakdown.
Failure to provide weekly skin assessments as ordered by the physician and failure to address physician orders for diagnostic testing in a timely manner following an unwitnessed fall.
Report Facts
Deficiencies cited: 3
Skin assessments missing: 3
Shower frequency: 2
Missed toileting activities: 15
Missed toileting documentation: 8
Missed bowel care documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/Staff #88) | Interviewed regarding reporting missing items and continence care | |
| Licensed Practical Nurse (LPN/Staff #73) | Interviewed regarding reporting missing items and skin checks | |
| Director of Nursing (DON/Staff #79) | Interviewed regarding reporting timelines, fall incident, skin assessments, and diagnostic testing delays | |
| Certified Nursing Assistant (CNA/Staff #89) | Interviewed regarding continence care and shower documentation | |
| Licensed Practical Nurse (Staff #8) | Documented progress notes related to resident condition after fall | |
| Registered Nurse (RN/Staff #35) | Contacted mobile imaging company regarding pending x-ray |
Inspection Report
Routine
Census: 69
Deficiencies: 5
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, PASARR screening, nurse aide performance reviews, medication management, and infection control practices at The Rehabilitation Center at the Palazzo.
Findings
The facility was found deficient in ensuring accurate and consistent documentation of resident code status, completion of PASARR level I screening, annual performance reviews for nurse aides, proper labeling and storage of medications, and adherence to enhanced barrier precautions for infection control.
Deficiencies (5)
Failure to ensure that a resident's code status was accurate and consistent in the medical record, risking care inconsistent with the signed advance directive.
Failure to ensure that a PASARR level I screening was processed for determination of need for PASARR level II for one resident.
Failure to complete a yearly performance review for 1 of 2 sampled Certified Nursing Assistants.
Failure to ensure medications were dated when opened, risking reduced drug effectiveness and adverse reactions.
Failure to ensure appropriate infection control measures were implemented and followed for one resident related to tube feeding, including failure to use gowns as required.
Report Facts
Residents affected: 69
Medication vial volume: 50
PASARR level II referral date: May 7, 2025
Performance review missing: 1
Medication expiration days: 28
Tube feeding calories: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff # 65 | Social Services Director | Identified PASARR screening issues and advance directive discrepancies |
| Staff # 79 | Director of Nursing (DON) | Interviewed regarding code status discrepancies, nurse aide performance reviews, medication labeling, and infection control |
| Staff # 81 | Assistant Director of Nursing (ADON) | Interviewed regarding code status, advance directives, medication storage, and infection control practices |
| Staff # 88 | Certified Nursing Assistant (CNA) | Interviewed regarding code status communication and enhanced barrier precautions |
| Staff # 12 | Certified Nursing Assistant (CNA) | Personnel file reviewed for performance evaluation |
| Staff # 63 | Licensed Vocational Nurse (LVN) | Interviewed regarding medication labeling and storage |
| Staff # 41 | Licensed Vocational Nurse (LVN) | Observed medication administration and interviewed about medication cart security |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 27, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse or misappropriation, failure to provide professional standard care including continence and shower care, failure to provide appropriate treatment and care according to orders, and failure to timely address physician orders following an unwitnessed fall.
Complaint Details
The complaint investigation revealed that an allegation of misappropriation for Resident #38 was not reported to the State Agency within the required 24-hour timeframe. Interviews with staff including CNA, LPN, and DON confirmed delays in reporting. Additional complaints involved failure to provide proper continence and shower care for Resident #102, and failure to provide weekly skin assessments and timely diagnostic testing following a fall for Residents #21 and #28 respectively. The resident's son reported lack of notification regarding the fall and injury.
Findings
The facility failed to report an allegation of misappropriation within the required 24-hour timeframe, failed to provide continence and shower care according to professional standards for one resident, failed to ensure weekly skin assessments were completed as ordered for one resident, and failed to timely address physician orders for diagnostic testing following an unwitnessed fall for another resident. These deficiencies posed risks of harm including potential skin breakdown, delayed injury detection, and delayed care.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to ensure services provided by the nursing facility meet professional standards of quality, specifically failure to provide continence and shower care according to professional standards for one resident, risking skin breakdown.
Failure to provide appropriate treatment and care according to orders, including failure to ensure weekly skin assessments were provided as ordered and failure to timely address physician orders for diagnostic testing following an unwitnessed fall.
Report Facts
Deficiencies cited: 3
Skin assessments missing: 3
Shower frequency: 2
Missed toileting activities: 15
Missed toileting documentation: 8
Missed bowel care documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #88 | Certified Nursing Assistant (CNA) | Interviewed regarding reporting missing items and fall response |
| Staff #73 | Licensed Practical Nurse (LPN) | Interviewed regarding reporting missing items and skin checks |
| Staff #79 | Director of Nursing (DON) | Interviewed regarding reporting timelines, fall incident, skin assessments, and care standards |
| Staff #89 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care and shower documentation |
| Staff #8 | Licensed Practical Nurse (LPN) | Documented progress notes related to Resident #28's fall and care |
| Staff #35 | Registered Nurse (RN) | Contacted mobile imaging company regarding pending x-ray |
| Staff #84 | Licensed Practical Nurse (LPN) | Documented progress notes related to Resident #28's altered mental status and pain |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 5
Date: Jun 27, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident rights, PASARR screening, nurse aide performance, medication management, and infection control.
Findings
The facility was found deficient in ensuring accurate and consistent documentation of residents' advance directives, completion of PASARR screenings, annual performance reviews for nurse aides, proper medication labeling and storage, and adherence to infection prevention and control protocols.
Deficiencies (5)
Failed to ensure that a code status was accurate and consistent in the medical record for one resident (#10).
Failed to ensure that a Pre-admission Screening and Resident Review (PASARR) level I was processed for determination of need for PASARR level II for one resident (#42).
Failed to complete a yearly performance review for 1 of 2 sampled Certified Nursing Assistants (CNA/Staff #12).
Failed to ensure that medications were dated when opened, risking reduced drug effectiveness and adverse reactions.
Failed to ensure appropriate infection control measures were implemented and followed for one resident (#44) related to tube feeding.
Report Facts
Residents affected: 69
Residents affected: 1
Residents affected: 1
Residents affected: 1
Certified Nursing Assistants sampled: 2
Certified Nursing Assistants without yearly review: 1
Medication vial volume: 50
Medication expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff # 65 | Social Services Director | Identified PASARR screening deficiencies and tax ID issues |
| Staff # 79 | Director of Nursing (DON) | Interviewed regarding code status discrepancies, CNA performance reviews, medication labeling, and infection control |
| Staff # 81 | Assistant Director of Nursing (ADON) | Interviewed regarding code status documentation and medication storage |
| Staff # 88 | Certified Nursing Assistant (CNA) | Interviewed regarding code status and infection control practices |
| Staff # 12 | Certified Nursing Assistant (CNA) | Personnel file reviewed for performance evaluation |
| Staff # 63 | Licensed Vocational Nurse (LVN) | Interviewed regarding medication labeling and administration |
| Staff # 41 | Licensed Vocational Nurse (LVN) | Interviewed regarding medication storage and administration |
Inspection Report
Capacity: 66
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
Off-site inspection to decrease licensed capacity from 236 to 66 completed.
Findings
Off-site inspection to decrease licensed capacity from 236 to 66 completed.
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 0
Date: Dec 2, 2024
Visit Reason
On-site investigation of complaints AZ00219503 and AZ00218536 with no deficiencies cited.
Complaint Details
Complaints AZ00219503 and AZ00218536
Findings
On-site investigation of complaints AZ00219503 and AZ00218536 with no deficiencies cited.
Inspection Report
Capacity: 66
Deficiencies: 0
Date: Sep 27, 2024
Visit Reason
No deficiencies found during off-site documentation review for change of ownership.
Findings
No deficiencies found during off-site documentation review for change of ownership.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 8, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to provide adequate notification/documentation upon resident transfer and a significant medication error involving administration of medications ordered for another resident.
Complaint Details
The complaint involved a medication error where a registry nurse administered the wrong medications to a resident on March 30, 2023. The nurse failed to change the screen in the electronic medical record to the correct resident, leading to administration of another resident's medications. The incident was reported to the Arizona State Board of Nursing and the facility filed a complaint. The resident was hospitalized due to complications including sepsis, hypoglycemia, and hypotension.
Findings
The facility failed to ensure proper notification to receiving providers upon resident discharge and failed to prevent a significant medication error where one resident was given medications intended for another, resulting in hospitalization. The investigation revealed inadequate documentation, lack of discharge summary, and failure to follow medication administration protocols.
Deficiencies (2)
Failure to transfer or discharge a resident without adequate reason and provide required documentation and notification to the receiving provider.
Failure to ensure residents are free from significant medication errors; one resident received medications ordered for another resident.
Report Facts
Date of resident discharge to hospital: Mar 30, 2023
Date of complaint filed with Arizona State Board of Nursing: Apr 7, 2023
Brief Interview for Mental Status (BIMS) score: 13
Medication administration time of error: 01:00 AM
Vital signs at time of medication error: Blood pressure 139/67; Pulse 60; Respirations 16; Glucose 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding lack of discharge summary and medication error |
| Administrator | Administrator | Interviewed about medication error incident and reporting |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed about medication administration procedures and identification |
Inspection Report
Routine
Census: 49
Deficiencies: 7
Date: Sep 8, 2023
Visit Reason
Routine inspection conducted to assess compliance with regulatory requirements including medication administration, care planning, infection control, and resident safety.
Findings
The facility was found deficient in multiple areas including failure to provide adequate discharge notification, incomplete reassessment of care plans for mental health, unsafe pain management practices, failure to monitor psychotropic medication effectiveness and duration, medication errors including administration of wrong medications to a resident, and inadequate infection control during catheter care.
Deficiencies (7)
Failure to ensure clinical record contained required notification/documentation to receiving provider upon resident discharge.
Failure to reassess and revise care planned interventions for effectiveness for a resident with mental health needs.
Failure to provide safe and appropriate pain management; oxycodone administered outside prescribed parameters and less than 4 hours apart without provider notification.
Failure to provide and follow-up on mental health services and psych consults as indicated for a resident with major depression.
Failure to ensure drug regimen free from unnecessary drugs; psychotropic medications not monitored for effectiveness and PRN opioid medication lacked limited duration.
Resident received medications ordered for another resident resulting in adverse effects and hospitalization; lack of investigation and self-report.
Failure to maintain infection prevention and control during catheter care; gloves not changed appropriately increasing risk of infection transmission.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 49
Medication administration errors: 5
Medication administration errors: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding discharge notification, pain management, psych consult tracking, and medication error investigation |
| Social Services Director | Social Services Director | Interviewed regarding psych consult referrals and resident mental health follow-up |
| Certified Nursing Assistant | Certified Nursing Assistant | Interviewed regarding mood/emotional concerns and catheter care observation |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding pain management and medication administration procedures |
| Administrator | Administrator | Interviewed regarding medication error incident and reporting |
| Wound Care and Infection Preventionist | Wound Care and Infection Preventionist | Interviewed regarding catheter care procedures and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide adequate notification/documentation upon resident transfer and a significant medication error involving administration of medications ordered for another resident.
Complaint Details
The complaint involved a medication error where a registry nurse administered the wrong medications to resident #4 on March 30, 2023. The nurse failed to change the screen in the electronic medical record to the correct resident, leading to administration of another resident's medications. The incident was reported to the Arizona State Board of Nursing and the facility. The resident was hospitalized with complications including sepsis, hypoglycemia, and hypotension.
Findings
The facility failed to ensure proper notification to the receiving provider upon resident transfer and failed to prevent a significant medication error where one resident received medications intended for another, resulting in hospitalization. The investigation revealed deficiencies in documentation, communication, and medication administration practices.
Deficiencies (2)
Failure to provide required notification/documentation to receiving provider upon resident transfer.
Failure to ensure resident was free from significant medication errors; resident received medications ordered for another resident.
Report Facts
Residents Affected: 1
Medication doses administered incorrectly: 8
Date of medication error incident: Mar 30, 2023
Date of complaint filed: Apr 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding lack of discharge summary and medication error investigation |
| Administrator | Administrator | Interviewed about medication error incident and reporting |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed about medication administration procedures and resident identification |
Inspection Report
Routine
Census: 49
Deficiencies: 7
Date: Sep 8, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, care planning, infection control, and resident safety.
Findings
The facility was found deficient in multiple areas including failure to provide adequate discharge notification for a transferred resident, incomplete reassessment and follow-up of mental health care plans, unsafe pain medication administration practices, failure to monitor psychotropic medication use appropriately, medication errors involving administration of another resident's medications, and inadequate infection control practices during catheter care.
Deficiencies (7)
Failure to ensure clinical record contained required notification/documentation to receiving provider upon resident transfer.
Failure to reassess and revise care planned interventions for a resident with depression.
Failure to provide safe, appropriate pain management; oxycodone administered outside ordered parameters and less than 4 hours apart without provider notification.
Failure to provide appropriate treatment and follow-up for a resident's diagnosed mental health condition.
Failure to ensure drug regimen free from unnecessary drugs; psychotropic medications not monitored and PRN psychotropics lacked limited duration.
Resident received medications ordered for another resident resulting in adverse effects and hospitalization.
Failure to maintain infection prevention and control during catheter care; gloves not changed appropriately increasing risk of infection.
Report Facts
Residents affected: 49
Medication administration outside parameters: 11
Psychotropic medication PRN duration: 14
Medication error incident date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding discharge notification, psych consult tracking, pain management, and medication errors |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding psych consult referrals and resident #33's mental health follow-up |
| Certified Nursing Assistant | CNA | Interviewed and observed during catheter care; noted failure to change gloves appropriately |
| Licensed Practical Nurse | LPN | Interviewed regarding medication administration and resident monitoring |
| Administrator | Facility Administrator | Interviewed regarding medication error incident and reporting |
| Wound Care and Infection Preventionist | Infection Preventionist | Interviewed regarding catheter care infection control practices |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The inspection was conducted as a routine annual survey of The Rehabilitation Center at the Palazzo to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of The Rehabilitation Center at the Palazzo.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Capacity: 60
Deficiencies: 13
Date: Jul 28, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, infection control, medication administration, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide timely written transfer/discharge notices, incomplete PASARR screening, medication administration errors, inadequate personal hygiene and incontinence care, inaccurate advance directive documentation, inconsistent infection control surveillance and antibiotic stewardship, improper laundry PPE use, and incomplete staff training on abuse and dementia care.
Deficiencies (13)
Failure to provide timely written notice of transfer/discharge to resident and representative.
Failure to provide evidence of Level 1 PASARR screening for one resident.
Failure to ensure medications were administered according to professional standards for two residents.
Failure to provide consistent personal hygiene and toileting care for one resident.
Failure to provide appropriate incontinence care and bladder training for two residents.
Failure to administer medications according to physician parameters for one resident.
Failure to obtain and report laboratory test results as ordered for diabetic management for one resident.
Failure to ensure dishwasher sanitation was consistently monitored, risking foodborne illness.
Failure to maintain accurate advance directive information for two residents.
Failure to develop and implement a plan of action to correct infection control surveillance and antibiotic stewardship deficiencies.
Failure to consistently implement infection prevention and control program including safe handling of soiled linens.
Failure to implement a program that monitors antibiotic use.
Failure to provide staff education on abuse, neglect, exploitation, and dementia care for three staff members.
Report Facts
Facility licensed capacity: 60
Medication administration errors: 14
Blood sugar checks not done: 26
Staff missing training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Interviewed regarding transfer/discharge notification and medication administration | |
| Director of Nursing | Interviewed regarding transfer/discharge notification, medication administration, infection control, and staff training | |
| Social Services Coordinator | Interviewed regarding PASARR screening and incontinence care documentation | |
| Licensed Practical Nurse | Interviewed regarding medication administration and blood sugar monitoring | |
| Certified Nursing Assistant | Interviewed regarding personal hygiene and incontinence care | |
| Executive Director | Interviewed regarding QAPI, infection control surveillance, and antibiotic stewardship | |
| Infection Preventionist | Interviewed regarding infection control surveillance and antibiotic stewardship | |
| Human Resource Assistant | Interviewed regarding staff training compliance | |
| Director of Human Resources | Interviewed regarding staff training compliance | |
| Laundry Aide | Observed and interviewed regarding PPE use during laundry handling | |
| Director of Housekeeping and Laundry | Interviewed regarding laundry PPE policies and practices | |
| Executive Chef/Certified Dietary Manager | Interviewed regarding dishwasher sanitation monitoring |
Inspection Report
Capacity: 60
Deficiencies: 13
Date: Jul 28, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, infection control, medication administration, advance directives, and facility quality assurance.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notice of resident transfer, incomplete PASRR screening, medication administration errors, inadequate hygiene and incontinence care, inaccurate advance directive documentation, inconsistent dishwasher sanitation monitoring, lack of infection control surveillance and antibiotic stewardship, and incomplete staff training on abuse and dementia care.
Deficiencies (13)
Failed to provide written notice of transfer/discharge to resident and representative.
Failed to provide evidence of PASARR Level 1 screening for a sampled resident.
Failed to ensure two residents received medications according to professional standards of practice.
Failed to ensure one resident consistently received necessary hygiene services.
Failed to provide incontinence care and appropriate continence services for two residents.
Failed to ensure one resident was administered medications according to physician-ordered parameters.
Failed to obtain and report lab results as ordered related to diabetic management for one resident.
Failed to ensure dishwasher sanitation was consistently monitored.
Failed to safeguard resident-identifiable information and maintain accurate advance directive documentation for two residents.
Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action related to infection control and antibiotic stewardship.
Failed to consistently implement an ongoing system of surveillance for infections and failed to handle potentially soiled linens using safe and sanitary techniques.
Failed to develop and implement a facility-wide system to monitor antibiotic use.
Failed to provide evidence that 3 out of 10 staff received training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management.
Report Facts
Facility licensed capacity: 60
Medication administration errors: 14
Blood sugar checks not done: 14
Staff missing training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Interviewed regarding transfer notification and medication administration | |
| Director of Nursing | Interviewed regarding transfer notification, medication administration, infection control, and quality assurance | |
| Social Services Coordinator | Interviewed regarding PASRR screening and incontinence care documentation | |
| Licensed Practical Nurse | Interviewed regarding medication administration and blood sugar monitoring | |
| Certified Nursing Assistant | Interviewed regarding hygiene and incontinence care | |
| Executive Director | Interviewed regarding quality assurance and infection control | |
| Human Resource Assistant | Interviewed regarding staff training | |
| Director of Human Resources | Interviewed regarding staff training | |
| Infection Preventionist | Interviewed regarding infection control surveillance and antibiotic stewardship | |
| Laundry Aide | Observed and interviewed regarding PPE use in laundry | |
| Director of Housekeeping and Laundry | Interviewed regarding laundry PPE and procedures |
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