Palazzo Post Acute

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of three sample resident (Resident 1)'s privacy was respected whenRespiratory therapy (RT) 1 did not introduce himself and asked for permission before entering Resident 1's room. In addition, Certified Nursing Assistant (CNA) 1 did not knock on the door, introduced himself and asked for permission before entering room [ROOM NUMBER] and room [ROOM NUMBER]. These deficient practices resulted in residents' privacy being not respected and negatively affecting their care.1. [...]

Inspectors wroteBased on observation, interview, and record, facility failed to ensure proper hand hygiene, when Certified Nursing Assistant (CNA) 1 observed entered and exited room [ROOM NUMBER] without performing hand hygiene and then immediately entered room [ROOM NUMBER] without performing hand hygiene again. This deficient practice increases the risk of transmitting infections among residents in room [ROOM NUMBER] and room [ROOM NUMBER]. During an observation on 7/22/2026 at 1:05 pm at the hallway, CNA 1 entered and exited room [ROOM NUMBER] without performing hand hygiene, then immediately entered room [ROOM NUMBER] without sanitizing hands. During an interview on 7/22/2026 at 1:10 pm with CNA 1, CNA 1 stated, he did not wash his hand inside room [ROOM NUMBER] or room [ROOM NUMBER], he forgot to use hand sanitizer outside of the rooms. CNA 1 stated his action can cause infection control issues. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 8 and Resident 13) reviewed for dialysis (a medical treatment that acts as an artificial kidney, filtering waste products, toxins, and excess water from the blood when a person's kidneys can no longer perform these tasks properly) received dialysis services consistent with professional standards of practice by failing to:-Ensure Resident 8 did not miss dialysis appointments due to transportation on 5/16/2026.-Ensure the licensed nurses (in general) conducted the pre (before) and post (after) dialysis assessments for Resident 8 and Resident 13.-Ensure Resident 13 did not receive more than 1000 milliliters (ml, a unit of measurement) of fluid per day as ordered by Resident 13's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four dumpsters were completely closed and not overfilled with trash. This failure had the potential to result in pests (organisms that cause harm to humans such as flies, cockroaches, and rodents) entering the facility and spreading diseases to residents.

Inspectors wroteBased on interviews, and record review, the facility failed to maintain ongoing competency for restorative nursing assistants (RNAs) by failing to, ensure a restorative nursing assistants training program was developed and implemented. This failure had the potential to compromise nursing competence among restorative nursing assistants which could adversely affect the quality and safety of care provided to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a manner that promoted or enhanced dignity and respect for two of 20 sampled residents (Resident 4 and Resident 41) by failing to:-Ensure barber services were provided for Resident 4, resulting in the resident not receiving grooming care needed to maintain personal dignity and appearance.-Ensure the facility communicated with Resident 41 regarding an active Out on Pass (OOP) order dated [DATE], resulting in the resident not being informed of the authorized pass and not being provided the opportunity to participate in planning and exercising their personal rights related to temporary leave from the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment that was free from accident hazards for one of seven sampled residents (Resident 82) by failing to: -Ensure Resident 82 did not have unattended veterinary liniment gel (medication applied to the skin designed to relieve muscle and joint pain in animals) container at bedside. This failure had the potential to result in unsafe medication administration to Resident 82.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 66) reviewed for urinary catheter (a flexible tube inserted into the bladder to drain urine) received appropriate catheter treatment and services by failing to: -Ensure Resident 66's urinary catheter tubing did not have sediment (particles that may be indicative of an infection). This failure had the potential to result in the backflow of urine into Resident 66's bladder, which could cause urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract), and could negatively impact the delivery services provided to Resident 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of a controlled medication (medication with a high potential for abuse; medication use and possession of are controlled by the federal government) for one of three inspected medication carts (Medication Cart 1-Med Cart 1) by failing to: 1. Ensure Med Cart 1 had accurate documentation of Resident 28's Methadone Hydrochloride (HCI) [a controlled medication used to treat severe, long-lasting pain] medication on narcotic and hypnotic record (NHR- a document indicating continuous inventory and administration of controlled substances) after Licensed Vocational Nurse 4 (LVN 4) administered methadone HCI to Resident 28 on 6/25/2026 at 8:07 AM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to:1. Ensure the staff wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) per facility policy and procedures (P&P) titled , Enhanced Barrier Precautions (EBP) reviewed on 5/21/2026. By failing to ensure Certified Nursing Assistant 3 (CNA 3) wore a gown when providing personal basic care to Resident 97 who was on enhanced barrier precautions (EBP-infection control strategy for nursing home, requiring gowns and gloves to be used during high-contact care for residents with or at high risk for multidrug-resistant organisms [MDRO]).2. Ensure one out of one pill crushers located at the nurse's station was kept clean. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of five sampled residents (Resident 77) reviewed for immunizations, by failing to:1. Ensure to re-offer Resident 77 the pneumococcal (Pneumonia [PNA]-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccine yearly, in accordance with facility policy and procedures (P&P) titled Pneumococcal Vaccine reviewed by the facility on 5/21/2026 and the current standards of practice. This failure placed Resident 77 at a higher risk of acquiring and transmitting vaccine-preventable respiratory infections, including influenza and pneumonia, to other residents, visitors and staff within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to document itemized list of personal property for one of three sampled residents (Resident 2) upon admission. This failure had the potential for loss or misappropriation of Resident 2's personal property items and to cause moral distress to Resident 2.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a clean and comfortable environment for one of three sampled residents (Resident 3). This failure resulted in Resident 3's room area to remain cluttered with the resident care items on the dresser, resident's personal blanket left on the bed frame out of the resident's reach alongside an empty Glucerna shake bottle and white paper bag with old crackers, as well as, a wedge a triangular-shaped orthopedic pillow, usually made of firm foam, designed to elevate specific parts of your body) on the floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 picked up a call light (device for residents to call for help) from the floor and placed it on the bed sheet without cleaning it. This failure had the potential for Resident 1 to be in unsanitary environment and be exposed to disease-causing germs.

Inspectors wroteBased on interview and record review the facility failed to ensure one of six sampled Certified Nursing Assistants (CNA) (CNA 3) had an active license when working an 11pm to 7am shift on [DATE]. This failure resulted in CNA 3 not meeting the requirements of the federal regulation for nurse aide registry certification and had the potential to effect the quality of care received for her assigned residents. During a concurrent interview and record review on [DATE] at 4:30 pm with Director of Nursing (DON) CNA 3's L & C (Licensing & Certification) Verification Detail Page, undated, from CNA 3's personnel file was reviewed. The page indicated CNA 3's license status was active, employable with expiration date of [DATE], which the DON verified. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to create and implement a Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the individual needs for one of three sample residents (Resident 1) care plan, by failing to: 1. Create and implement a care plan on 11/29/2025 when the resident displayed aggressive behavior and was placed on 1:1supervision (one staff member always stays with one patient to keep them from harming others or themselves). 2. Create and implement a care plan on 12/8/2025 when the resident was readmitted to the facility from the GACH (General Acute Care Hospital) after being evaluated for increased agitation with aggression. These deficient practices had the potential to delay and affect the quality of care and services Resident 1 received.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (any intentional act causing injury or trauma to another person by way of bodily contact) by failing to: -Ensure Certified Nursing Assistant 2 (CNA2) notified Registered Nurse 2 (RN2) that Resident 1 was agitated (to be visibly worried, upset, or restless, often showing this feeling through your movements or voice, like fidgeting or speaking in a tense way) when CNA1 did not allow Resident 1 to go smoke on 9/9/2025 at approximately 1AM. -Ensure Resident 2 did not hit Resident 1 who was blind on the left jaw (the lower part of the face below the mouth) on 9/9/2025 at 1AM. On 9/9/2025 at approximately 1AM, Resident 1 wanted to go smoke and CNA2 told Resident 1 to sit down. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise two of three residents (Resident 1 and Resident 2) by failing to: -Ensure Certified Nursing Assistant 2 (CNA2) notified Registered Nurse 2 (RN2) that Resident 1 was agitated (to be visibly worried, upset, or restless, often showing this feeling through your movements or voice, like fidgeting or speaking in a tense way) when CNA1 did not allow Resident 1 to go smoke on 9/9/2025 at approximately 1AM. -Ensure Resident 2 did not hit Resident 1 who was blind on the left jaw (the lower part of the face below the mouth) on 9/9/2025 at 1AM. -Ensure Resident 1 and Resident 2 had adequate supervision to prevent Resident 2 from hitting Resident 1 on his jaw. On 9/9/2025 at approximately 1AM, Resident 1 wanted to go smoke and CNA2 told Resident 1 to sit down. [...]

Inspectors wroteBased on interview and record review the facility failed to implement the care plan interventions to prevent falls for one of three sampled residents (Resident 1). For Resident 1, the facility failed to anticipate Resident 1 ' s needs during transfer from the toilet to the wheelchair on 2/19/25. This deficient practice resulted in Resident 1 sliding off the wheelchair and fell to the floor. Resident 1 had the potential to sustain injury because of the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure to receive the receipt of a correct emergency drug supplies (E-kit, a pre-set of medications to provide an immediate service to facility's residents) from the pharmacy upon delivery. As a result, the facility did not have a narcotic (controlled drugs) E-kit available in the facility for roughly twenty-four (24) hours, between 6/2/2025 and 6/3/2025. 2. Ensure an E-kit was replaced within 72 hours of first use. 3. Ensure seven of seven drug disposition forms were filled out with dates of disposition, nurse and witnessing nurse's signatures. 4. Ensure to follow up on Resident 69's Norco (a potent opioid and narcotic that treats pain) 10-325 milligrams (mg, unit to measure mass) ordered on 5/28/2025 until 6/4/2025, after surveyor's inquiry. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure to keep the ice scooper holder clean. 2. Ensure the kitchen staff (in general) did not keep their personal perishable food in the facility's refrigerator and did not place their personal belongings anywhere in the kitchen other than the designated area for staff. These failures had potential for residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to follow infection control practices by failing to: 1. Develop a sufficient water management plan (a program that identifies hazardous conditions and steps to take to minimize the growth and spread of waterborne pathogens in building water systems) to reduce the growth and spread of Legionella (bacteria that causes Legionnaires Disease, a severe lung infection. Legionella is often found in water systems and is spread by breathing in mist or swallowing water that is contaminated by the bacteria) amongst 97 out of 97 facility residents. 2. Ensure the nursing staff (Licensed Vocational Nurse 3 [LVN3]) followed its enhanced barriers precautions (EBP, an infection prevention protocol) policy during the medication administration observation for one of five sampled residents (Resident 69). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 9) who did not have the capacity to understand and make decisions had a legal representative to assist in making medical decisions. This failure violated Resident 9's right to make an informed decision (choice that individuals make once they have all the information related to the decision topic) in the resident' care.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for one of five sampled residents (Resident 47) related to the risk for falls after Resident 47 had a fall on 12/26/2024. This failure had the potential for Resident 47 to receive inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to provide effective oral hygiene care for one of five sampled residents (Resident 39). This failure resulted in Resident 39 having a tan substance on her teeth, dry lips, and a substance on her reddened, tongue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to implement safety measures for one of one sampled residents (Resident 63) by failing to: -Ensure Certified Nursing Assistants (CNA2 and CNA3) locked Resident 63's bed and the Hoyer lift (a specialized lifting device to weigh or safely transfer a patient with limited mobility) prior to placing the sling (a specialized fabric support, acts as a harness) under Resident 63 on 6/2/2025 at 10:58 AM. This failure had the potential to cause physical injury to Resident 63.

Inspectors wroteBased on interview and record review, the facility failed to perform a bowel and bladder assessment (a process to evaluate a person's bowel and bladder function) quarterly as indicated in the care plan for one of one sampled residents (Resident 66). This failure had the potential for Resident 66 to not receive the appropriate care for her bowel and bladder function.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled residents (Resident 1) had a labeled flush bag for the gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential for Resident 1 to be exposed to infection.

Inspectors wroteBased on interview and record review the facility failed to administer medication as ordered by the physician for one of five sampled residents (Resident 1). For Resident 1, the facility failed to administer the Benadryl (medication that treats the symptoms of allergies and allergic reaction) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) on 3/28/25 when Resident 1 complained of facial itching due to possible allergic reaction. This deficient practice had the potential for Resident1 to continue experiencing allergic reaction and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public for one of one sampled day (11/12/2024). As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a system to consistently and accurately reconcile Pomalyst (pomalidomide- is an oral chemotherapeutic (a drug used to treat cancer) capsule treatment for Multiple Myeloma [a blood cancer that develops in plasma cells in the bone marrow]) oral capsule (cap) 4 Milligrams (MG) for one of the three sampled residents (Resident 1). This failure resulted in Resident 1 missing a total of 2 dosages on 5/18/24 and 7/13/24.

Inspectors wroteBased on interview, and record review, facility failed to ensure dignity and respect for two of seven sampled residents (Residents 2 and 7). This failure resulted in Residents 2 and 7 not being treated with dignity and respect and had the potential to affect the resident ' s self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services for the resident's change in condition of loose stools for one of two sampled residents (Resident 74). Resident 74 continued to receive a laxative (medication used to treat constipation) and experience frequent loose stools without appropriate intervention. This deficient practice had the potential for Resident 74 to become dehydrated (a condition that occurs when you lose more fluid than you take in, not having enough water to carry out its normal functions) and potentially cause kidney damage, brain damage, and/or death.

Inspectors wroteBased on interview and record review the facility failed to ensure the transfer records from the general acute hospital (GACH 1) were reviewed thoroughly for one of two sampled residents (Resident 1). For Resident 1, who had appointments arranged by the general acute hospital (GACH 1) for vascular diagnostic (a test used to determine possible circulation problems of the blood vessels), chemotherapy (use of drugs to destroy cancer cells), hematologist (medical doctor who had special training in diagnosis and treating blood disorders) and pulmonologist (medical doctor who had special training in diagnosing and treating diseases of the lungs (body organ that helps with breathing) prior to Resident 1's transfer and admission to the facility on 3/16/24, the facility failed to: 1. Thoroughly review Resident 1's GACH 1 transfer record when the facility admitted Resident 1 on 3/16/24. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to safeguard personal funds for one of three sampled residents (Resident 1). The Licensed Vocational Nurse (LVN) 1 retrieved $800 from Resident 1 and placed the money in the narcotic box. This failure had the potential to result in Resident 1's personal funds becoming stolen or misused.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse. This failure had the potential to result in mental anguish, depression, anxiety and has the potential to result in physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide an environment free of accident hazards and supervision for one of two sampled residents, (Resident 3), who was a high fall risk and had history of falls with fracture (broken bones). On 10/16/2021, at 9 AM, the Certified Nursing Assistant 1 (CNA 1) assisted the resident to the activity room, where Resident 3 remained alone, unsupervised. As a result, at 9:20 AM, Resident 1 was found in the activity room, lying on her left side near her wheelchair, and complained of moderate pain to the left hip and left thigh. On 10/17/2021, Resident 3 was diagnosed with a left hip fracture requiring transfer to General Acute Care Hospital (GACH) on 10/18/2021.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures as isolation gowns were disposed of in unlidded disposal bins in resident rooms 41, 43, 45, and 47, and Certified Nursing Assistant 5 (CNA 5) was observed feeding one of 35 sampled residents (Resident 57) in a designated yellow zone room (area in the facility designated for residents that are under observation for COVID-19, a respiratory disease caused by coronavirus) without wearing gloves. These deficient practices had the potential to result in the possible spread of COVID-19 to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one of 35 sampled residents (Resident 45) when Resident 45's call light (device used to call for assistance from the facility staff) was observed hanging off the resident's bed. This deficient practice had the potential for Resident 45 to have the inability to call the facility staff for help when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for two of 35 sampled residents (Resident 45, Resident 24) when Resident 45 stated the noise levels in the facility bothered her and Resident 24 could hear staff clock out. This deficient practice caused an increase risk to disturb the sleep schedule of the residents and not allow them to receive enough rest.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 3). Resident 3 did not have an accurate assessment for cognitive skills for daily decision making. This deficient practice had the potential to result in Resident 3's delay in necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice and implement a physician's written order for a pain management consult for one of three sampled residents (Resident 17). This deficient practice had the potential to place Resident 17 at risk for increased levels of pain and a decrease in daily function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received proper assistive devices to maintain hearing abilities by not assisting in the arranging for an audiologist referral consult for one of three sampled residents (Resident 3). This deficient practice resulted in a delay of services and Resident 3 not being able to hear adequately.

Inspectors wroteBased on interview and record review, the facility failed to meet State licensure requirements for Physical Therapy and Occupational Therapy to have a hands-free sink in the rehabilitation room as outlined in the California Code of Regulations, Title 22. This deficient practice had the potential to prevent a sanitary environment in the rehabilitation area.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for three of 36 sampled residents (Resident 45, Resident 62 and Resident 85) by failing to accurately document Restorative Nursing Assistant (RNA) interventions performed on Resident 45 and Resident 62. The facility failed to document records accurately and completely when administering a narcotic medication to Resident 85. These failures had the potential to result in the lack of or delay of care services to the residents as well as the potential to result in confusion and incomplete assessment of the resident's needs.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, sanitary, comfortable, environment for one of three sampled residents (Resident 43). Resident 43 had a soiled toilet which was documented as cleaned every hour. This deficient practice may have resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life.