Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Rehabilitation Center At The Palazzo during CMS and state inspections, most recent first.
A resident with paraplegia, depression, and generalized weakness, who was cognitively intact, requested transfer to another SNF after a staff member told her she was in the wrong (short-term) facility and should look into another placement for long-term care. Social services initiated an SNF-to-SNF referral and discussed transfer procedures with an individual initially treated as a family/POA, later clarified to be a non-family contact authorized by the resident. The facility issued same-day written transfer/discharge notice citing improved health and no longer needing services, and nursing documented the resident’s departure and notification of a POA/family member, but there was no documentation that the OSLTCO was notified at the same time as the resident, nor evidence of discharge planning in the care plan. The resident reported she only signed with an initial, did not understand her appeal rights or the option to consult an ombudsman, and the OSLTCO and facility leadership confirmed that the facility only provided monthly notifications and lacked a specific policy for ombudsman notification for non-emergency transfers.
The facility did not ensure that its services met professional standards of quality, as observed during the survey. The report does not specify particular actions, residents, or incidents involved.
The facility failed to complete weekly skin assessments as ordered for a resident, with multiple missed assessments over several weeks, and did not ensure timely completion of diagnostic imaging for another resident after an unwitnessed fall. The resident who fell experienced pain and altered mental status, with a significant delay in x-ray completion and family notification. Staff interviews confirmed gaps in assessment processes and documentation.
A resident with a history of falls and hemiplegia, who required assistance with mobility, experienced a fall after sliding out of bed when a fitted sheet was not in place on a new alternating pressure pad. Staff interviews confirmed that all residents should have full linens, and the absence of a fitted sheet was contrary to facility policy, contributing to the incident.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple medical conditions and intact cognition reported missing cash and a debit card to staff. Facility staff searched for the items over several days, eventually locating the debit card but not the cash. The DON acknowledged that the incident was not reported to the State Agency within the required 24-hour timeframe, citing the resident's request to delay reporting. Facility policy required timely reporting of such allegations, but this was not followed.
Failure to Notify Ombudsman of Resident Transfer and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to notify the Office of the State Long-Term Care Ombudsman (OSLTCO) of a resident’s non-emergency transfer to another skilled nursing facility at the same time notice was provided to the resident. The resident was admitted with diagnoses including unspecified dislocation of the left knee (subsequent encounter), unspecified paraplegia, unspecified depression, and generalized muscle weakness, and had an admission MDS BIMS score of 14, indicating intact cognition. A referral for transfer from one SNF to another was initiated on February 6, 2026, at the resident’s request, and social services documented that SNF-to-SNF transfer procedures were discussed with an individual initially identified as a family member/POA, who later clarified she was not a family member or POA but had the resident’s consent to receive information. On February 10, 2026, the facility issued a written notice of transfer/discharge with an effective date of the same day, citing that the resident’s health had improved sufficiently and she no longer required the facility’s services, and informing her that any appeal would need to be filed within 10 days of the notification. Nursing documentation on that date recorded that the resident left the facility and that a discharge assessment was completed, and that the transfer was reported to a POA/family member. However, there was no documentation in the clinical record or progress notes showing that the OSLTCO was notified of the transfer/discharge at the same time as the resident, nor was there evidence of additional detail regarding discharge planning discussions or inclusion of discharge planning in the resident’s care plan. In interviews, the OSLTCO stated that they had not received the discharge notice in a manner that would allow advocacy for the resident’s appeal rights and clarified that, aside from emergency hospital transfers or deaths (which may be reported monthly), facilities must provide notice of discharge to the resident or representative at least 30 days before discharge for other types of discharges. The resident reported that a male staff member told her she had been admitted to the wrong facility because it was a short-term facility and that she would need to look into another facility for long-term care, which upset her and influenced her desire to transfer. She stated she received notification of a potential placement the day before discharge, signed a document with only an initial, and was unaware of her right to appeal the transfer/discharge or to discuss the transfer with an ombudsman until later. The social services director and DON both stated they believed ombudsman notifications were done monthly and were unaware of additional expectations for notification related to non-emergency transfers, and there was no facility policy addressing ombudsman notification.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or incidents involved. No additional information regarding the medical history or condition of any residents at the time of the deficiency is provided in the report.
Failure to Complete Weekly Skin Assessments and Timely Diagnostic Testing After Fall
Penalty
Summary
The facility failed to provide weekly skin assessments as ordered by the physician for one resident and did not address physician orders for diagnostic testing in a timely manner for another resident following an unwitnessed fall. For the first resident, there were multiple periods where weekly skin assessments were not completed or documented, despite active physician orders requiring these checks. Nursing progress notes and charted assessments confirmed gaps in the completion of these assessments, and staff interviews corroborated that the process at the time relied on a single nurse, which resulted in missed assessments. For the second resident, after an unwitnessed fall, the facility did not ensure that ordered diagnostic imaging was completed promptly. The resident, who had a history of falls, multiple comorbidities including MS, diabetes, and chronic kidney disease, and was dependent for mobility, experienced a fall resulting in pain and a skin tear. Although a mobile x-ray was ordered, there was a delay of several days before the imaging was completed and the results were received, during which time the resident continued to experience pain and developed altered mental status. Documentation showed that staff followed up with the imaging company, but the x-ray was not performed until days after the initial order, and the resident was ultimately found to have a femoral fracture and was transferred to the hospital. Interviews with staff and the resident revealed that the resident was unable to reach the call light after the fall and that family notification was delayed, with the resident's son only learning of the injury through a relative. The DON confirmed the delay in imaging and stated that the resident's pain was not reported to be higher than baseline, which influenced the decision not to send the resident out for more urgent imaging. Facility policies reviewed indicated requirements for timely assessment and intervention following accidents and for regular skin assessments, which were not met in these cases.
Failure to Maintain Safe Bed Environment Results in Resident Fall
Penalty
Summary
A resident with a history of epilepsy, repeated falls, and left-sided hemiplegia was identified as being at risk for injuries from falls, with care plan interventions including ensuring the call light was within reach and providing supervision as indicated. The resident's MDS indicated intact cognition but significant physical impairment, requiring assistance with mobility and transfers. Despite these interventions, the resident was found on the floor after sliding out of bed. At the time of the fall, a new alternating pressure pad was in use, but there was no fitted sheet on the bed, only a flat sheet covering the mattress topper. The resident reported discomfort and sliding down the bed, and documentation confirmed the absence of a fitted sheet at the time of the incident. Staff interviews confirmed that all residents should have full linens, including fitted sheets, and that interventions for fall risk include low beds, fall mats, and frequent checks. The DON acknowledged that the resident had a low air-loss mattress and slid down the side of the bed due to the lack of a fitted sheet. The facility's policy requires the resident environment to remain as free of accident hazards as possible, but the omission of a fitted sheet contributed to the resident's fall.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property to the State Agency within the required 24-hour timeframe. A resident with chronic obstructive pulmonary disease, cirrhosis of the liver, and an above-knee amputation, who was cognitively intact, reported missing cash and a debit card to facility staff. The incident occurred when the resident noticed the items were missing and informed staff, who then searched for the items over the following days. The debit card was eventually found, but the cash remained missing at the time of the initial report. The facility did not submit the required report to the State Agency until more than 24 hours after the resident first reported the missing items. Interviews with staff, including a CNA, LPN, and the DON, revealed that the facility's practice was to search for missing items before reporting them as misappropriated, sometimes delaying the reporting process. The DON acknowledged that the report was not made within the mandated timeframe and stated that the delay was partly due to the resident's request to hold off on reporting. Facility policy required all allegations of misappropriation to be reported to the Administrator and appropriate agencies within specified timeframes, but this was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beatitudes Campus | 0.7 mi | — | 0 | 0 |
| Maryland Gardens Post Acute | 1.7 mi | — | 0 | 0 |
| Haven Of Phoenix | 2.2 mi | — | 1 | 0 |
| The Terraces Of Phoenix | 3.1 mi | — | 0 | 0 |
| North Mountain Medical And Rehabilitation Center | 3.3 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.