Palazzo Post Acute

In the surveyor’s words

From the most serious findings on record at Palazzo Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684May 9, 2024

  Based on interview and record review, the facility failed to identify and ensure one of three closed record residents (Resident 75), who had an amputation site (surgical removal of part of the body, left lower leg), acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), and a right lateral malleous (bony projection of the ankle) with arterial ulcer (injury to skin or underlying tissue caused by poor circulation, which in turn was caused by arterial insufficiency [reduced blood flow by the artery]) on the right lower leg, received necessary care and services in accordance with professional standards of practice by failing to: -Assess upon admission or on [DATE], and document the condition, description, and measurements of… […]

• Actual harm, isolatedF689Oct 24, 2022

  Based on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dementia (loss of memory, thinking and reasoning), had a history of fall, and was a high risk for falls, received care and services to prevent falls and injuries. The facility failed to: -Complete an accurate Fall Risk Assessment upon admission on [DATE], to identify underlying medical conditions that may increase the risk of injury from falls, per facility policy titled Fall Risk Assessment. -Develop and implement a care plan for Resident 1's unsafe behavior in his attempts to be independent beyond his abilities and his noncompliance to use the call light. […]

• Actual harm, isolatedF689Oct 21, 2021

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jan 9, 2021

  Based on observation, interview, and record review, the facility failed to ensure linens are processed at the appropraite temperatures for two of two washing machines (WM 1 and WM 2) as indicated in the facility's policy and procedures titled, Departmental (Environmental Services)- Laundry and Linen. This deficient practice had the potential to result in the spread of infection to all residents. Findings: During an interview with the Laundry Service Worker 1 (LSW 1), on 12/04/2020 at 12:20 PM, the LSW 1 stated she did not check the water temperature this morning for the laundry. The LSW 1 further stated she does not check the water temperature and was not taught how to check the water temperature. She stated she does not know where the water temperature log is located. […]

• No harm, potential for more than minimal, patternF698Jun 25, 2026

  Based 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… […]