Palazzo Post Acute: Call Light Left on Floor - CA
The resident, identified in inspection records only as Resident 1, was admitted to the facility with a fractured right femur and pubis, type 2 diabetes, and major depressive disorder. According to a federal inspection report from May 29, 2026, a state inspector observed him at 9:14 in the morning and asked him to press the call light. He couldn't reach it.
He explained it this way: he doesn't usually call for help. He gets up and walks himself, uses his walker. The call light, he said, was for emergencies.
That's a significant thing for a man in his situation to say. His own care plan, dated May 1, flagged him as at high risk for falls. It specified that a call light should be within reach and answered promptly, and that staff should encourage him to use it when he needs help. A nursing assessment from earlier in the month found he needed moderate assistance with toileting and showering, and that transfers from his bed to a chair or toilet required more than half the effort to come from someone else.
Ten minutes after the inspector observed the resident unable to reach the device, a licensed vocational nurse confirmed what the inspector had already seen. The call light was on the floor, the nurse said, and not within the resident's reach. The nurse added that it was important for residents to have access to call lights, and that everybody was responsible for making sure they were within reach during rounds.
Nobody had.
The facility's own written policy, last updated just eight days before the inspection, states that the purpose of its call light procedures is to ensure timely responses to residents' needs and to ensure the device is accessible when a resident is in bed, on the toilet, in the shower, or on the floor. The policy covers the floor specifically.
The call light was on the floor.
Federal inspectors rated the violation as having the potential for actual harm, though they documented no injury to the resident as a result. The inspection was triggered by a complaint. Palazzo Post Acute is disputing the citation.
What the inspection doesn't answer is how long the call light had been there. The nurse's statement that everyone was responsible for checking during rounds suggests the expectation was that no single person owned the task, which can mean, in practice, that no one does. The resident's own explanation, that he walks himself and uses his walker and saves the call light for emergencies, suggests he had adapted to a situation where the device wasn't reliably available. A man at high risk for falls, recovering from broken bones in his thigh and pelvis, had concluded it was easier to get up himself.
The inspection covered three residents. The call light finding applied to one.
Palazzo Post Acute is a post-acute and rehabilitation facility in Los Angeles. The facility has not publicly explained its basis for disputing the citation.
The resident told the inspector he gets up and walks himself. He was recovering from a fractured femur. His call light was on the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palazzo Post Acute from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PALAZZO POST ACUTE in LOS ANGELES, CA was cited for violations during a health inspection on May 29, 2026.
According to a federal inspection report from May 29, 2026, a state inspector observed him at 9:14 in the morning and asked him to press the call light.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.