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🔎 Hollenbeck Palms

Inspection Results


Inspection Overview

Hollenbeck Palms has been cited for a total of 71 deficiencies since we began saving each survey.

In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Dispose of garbage and refuse properly.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: B

Post nurse staffing information every day.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-10-25
Correction Date: 2024-11-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2024-08-20
Correction Date: 2024-09-13
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-08-20
Correction Date: 2024-09-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-08-20
Correction Date: 2024-09-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2024-08-20
Correction Date: 2024-09-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-11-19
Correction Date: 2023-12-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-07-16
Correction Date: 2023-08-07
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2023-07-16
Correction Date: 2023-08-07
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-12-07
Correction Date: 2022-12-19
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-08-29
Correction Date: 2022-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-03-23
Correction Date: 2021-04-23
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-02-03
Correction Date: 2021-02-12
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-04
Correction Date: 2021-01-06
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-04-08
Correction Date: 2019-05-23
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-04-08
Correction Date: 2019-05-23
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-04-08
Correction Date: 2019-06-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-04-08
Correction Date: 2019-05-23
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2019-04-08
Correction Date: 2019-05-23
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2019-04-08
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2019-04-08
Correction Date: 2019-05-23
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2019-04-08
Correction Date: 2019-06-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-04-08
Correction Date: 2019-06-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-04-08
Correction Date: 2019-05-23
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2018-03-25
Correction Date: 2018-04-19
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Keep residents' personal and medical records private and confidential.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment by a qualified health professional.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Store, cook, and serve food in a safe and clean way.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Have a program that investigates, controls and keeps infection from spreading.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that a working call system is available in each resident's room or bathroom and bathing area.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2017-04-21
Correction Date: 2017-05-10
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**