Palazzo Post Acute

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.Findings: During a review of Resident 3's admission Record, dated 5/29/26, indicated the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, need for assistance with personal care, diabetes mellitus type two (DMII - a disorder characterized by difficulty in blood sugar control and poor wound healing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and anemia (a condition where the body does not have enough healthy red blood cells).

During a review of Resident 3's History and Physical (H&P) indicated the resident had capacity to make complex decisions.

During a review of Resident 3's Minimum Data Set (MDS - resident assessment tool), dated 4/13/26, indicated the resident cognition (ability to think, understand and make daily decisions) was intact.

The same MDS indicated Resident 3 was dependent to requiring maximal assist from staff with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and bed mobility.

During an observation with concurrent interview on 5/29/26 at 12:25 pm with Resident 3 in her bed area, the bed side table was observed cluttered with items for personal care (incontinence pads, two packages of incontinence briefs, a glove and comb) with the drawer left open. In the area behind the resident's bed a wedge pillow was on the floor, and the resident's personal blanket was bunched up on the bedframe under the raised head of the bed, an empty bottle of Glucerna (nutritional shake) and an crumbled white paper bag with old crackers were also observed on the bed frame and the floor was noted to be sticky.

The Resident verified the observations and stated that they (facility) don't seem to clean as they should, often leaving a mess. Resident 3 stated that she needs assistance for most tasks.

During an observation with concurrent interview on 5/29/26 at 12:36 pm, with Certified Nursing Assistant (CNA) 1 in Resident 3's room, CNA 1 verified the clutter and mess around the resident's bed. CNA 1 stated she (CNA 1) does not know how those (Resident 1's) items got under the head of the bed and on the floor and that those items should not be under the bed and on the floor. CNA 1 then began removing the items and tiding up Resident 1's area.

During a review of the facility's policy and procedures, Homelike Environment, reviewed 5/21/26, indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belonging to the extent possible.

056456 05/29/2026

Palazzo Post Acute 5400 Fountain Ave Los Angeles, CA 90029

Record, the admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses of fracture of right femur and pubis (fracture of right thigh and pelvic bones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), major depressive disorder (mood disorder that causes persistent sadness, loss of interest, and physical symptoms).

During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 5/5/2026, the MDS indicated Resident 1 was cognitively (the mental ability to make decisions of daily living) intact during Brief Interview for Mental Status (BIMS, an assessment tool for brain's complex mental processes involved in gaining knowledge and comprehension) and score was 13 (person able to verbalize needs and comprehend).

Under Functional Abilities (ability to move body and perform acts like dressing, walking), the MDS indicated that Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting and showering, and substantial/maximal assistance (helper does more than half the effort) with transfers from bed to chair, and toilet.

During a concurrent observation and interview on 5/29/2026 at 9:14 a.m. with Resident 1, Resident 1 stated he does not usually call for help, I get up and walk myself and walk with my walker.

They have a call light for emergencies.

When asked to press the call light Resident 1 could not reach the call light.

During concurrent observation and interview 5/29/2026 9:24 p.m. with LVN 1 in Resident 1's room, LVN 1 stated that Resident 1's call light was on the floor and not within the resident's reach. LVN 1 was observed to pick up the call light from the floor and placed the call light on the bed sheet without cleaning it. LVN 1 stated she should have cleaned the call light first before putting it on the sheet.

LVN 1 stated it is important to keep it clean to prevent contamination of bed linen.

During a review of policies and procedures (P & P) Infection Prevention and Control dated 5/21/2026, the P & P indicated, the purpose to maintain safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

056456 05/29/2026

Palazzo Post Acute 5400 Fountain Ave Los Angeles, CA 90029

bones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), major depressive disorder (mood disorder that causes persistent sadness, loss of interest, and physical symptoms).

During a review of the Minimum Data Set (MDS, resident assessment tool) dated 5/5/2026, the MDS indicated Resident 1 was cognitively intact during Brief Interview for Mental Status (BIMS, an assessment tool for brain's complex mental processes involved in gaining knowledge and comprehension) and score was 13 (person able to verbalize needs and comprehend).

The MDS indicated Functional Abilities (ability to move body and perform acts like dressing, walking) of Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting and showering, and substantial/maximal assistance (helper does more than half the effort) with transfers from bed to chair, and toilet.

During a concurrent observation and interview on 5/29/2026 at 9:14 a.m. with Resident 1, Resident 1 stated he does not usually call for help, I get up and walk myself and walk with my walker.

They have a call light for emergencies.

When asked to press the call light Resident 1 could not reach the call light.

During concurrent observation and interview 5/29/2026 9:24 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 1's call light was on the floor and was not within the resident's reach. LVN 1 stated, it was important to have call light to call help if needed, and everybody was responsible for ensuring call lights were within reach during the rounds.

During a record review of care plan (CP) for Resident 1 with Focus area At high risk for falls, dated 5/01/2026, the CP indicated that Call light within reach and answered promptly.

Encourage the resident to use it for assistance as needed.

The resident needs prompt response to all request for assistance.

During record review the facility's policy and procedures (P & P) titled Answering the Call Light dated 5/21/2026, the P & P indicated that, the purpose to ensure timely responses to the residents' requests and needs and to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.