Hollenbeck Palms

In the surveyor’s words

From the most serious findings on record at Hollenbeck Palms, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 11, 2026

  Based on observation, interview, and record review, the facility failed to provide supervision (the act of overseeing, managing, or directing a person, group, or process to ensure tasks are completed correctly and safely) or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance [when a caregiver keeps one or two hands on the patient's body at all times to steady the patient's balance) as indicated in the Minimum Data Set (MDS, resident assessment tool) for one (1) of three (3) sampled residents (Resident 1), who had a prior history of falls. […]

• Actual harm, isolatedF689Aug 20, 2024

  Based on interview and record review, the facility failed to prevent multiple fall (unintentional descent that results in a coming to a rest on the floor, on or against another surface, on another person, or an object) of one of two sampled residents (Resident 1) by: 1. Failing to develop and implement a fall care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for Resident 1's actual fall on 6/30/2024, 7/24/2024, and 8/2/2024 per facility policy. 2. […]

• Actual harm, isolatedF689Aug 29, 2022

  Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who was assessed as having severely impaired cognition, required constant re-directing/cueing, high risk for falls, and exhibited wandering behavior with an increased need of supervision was provided a safe environment by failing to: 1. Identify an environmental hazard, to prevent and control adverse outcomes as indicated in the facility's policy for accident prevention, by removing an unsecured nylon-like curtain cord (string) hanging freely forming a loop (twist) on a traverse rod mounting (a metal rod or track with a pulley mechanism for drawing curtains) attached to the ceiling by the window inside the room of Resident 1. 2. […]

• No harm, potential for more than minimal, widespreadF880Oct 25, 2024

  Based on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to: 1. Ensure staff wear Personal Protective Equipment (PPE, protective clothing such as gown, gloves, goggles, mask) before administering medication to Resident 35 via gastrostomy tube (G-tube, a surgically inserted tube that provides a way to deliver nutrition, fluids, and medications directly to the stomach) on 10/24/2024. This deficient practice had the potential to result in Resident 35 developing an infection and spread of infection among staff and residents. 2. […]

• No harm, potential for more than minimal, widespreadF812Jul 16, 2023

  Based on observation, interview, and record review the facility failed to maintain a safe and sanitary environment for food storage and food preparation areas by having: 1) Active cockroach (a small scavenging insect capable of spreading bacteria and viruses) infestation in the food preparation area (kitchen). 2) Damaged wall and floor tiles in the kitchen. 3) Food served to residents from facility ' s kitchen after County of Los Angeles Department of Public Health ' s Environmental Health Division (the Authority Having Jurisdiction) had suspended the Public Health Permit. These deficient practices had the potential to result in food contamination and introduce food-borne pathogens (disease causing bacteria and viruses such as e. Coli, Salmonella, norovirus, etc. […]