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Complaint Investigation

Hollenbeck Palms

February 24, 2026 · Los Angeles, CA · 573 S. Boyle Ave.
Citations 1
CMS Rating 4/5
Beds 106
Provider ID 055115
Healthcare Facility
Hollenbeck Palms
Los Angeles, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

HOLLENBECK PALMS in LOS ANGELES, CA — inspection on February 24, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0684
Quality of Life and Care Deficiencies

During a concurrent interview and record review on 2/24/2026 at 4 PM with the ADON, the P&P titled Medication and Treatment Administration Records, revised 1/2026, was reviewed.

The P&P indicated medications and treatments shall be administered as prescribed by the physician and shall be recorded by the responsible licensed nurse as the medication and/or treatment is provided.

The attending physician shall be notified in the event an order cannot be administered as prescribed. ADON stated the P&P indicated the attending physician shall be notified in the event that an order cannot be administered as prescribed and when a resident's routine medication was withheld, the explanation is to be recorded in the nurses' notes/comments. ADON stated the physician should have been notified that the bisoprolol was not given due to Resident 1's low BP and HR by RN 1.

The ADON also stated RN 1 should have also documented in the resident's progress notes the reason why the bisoprolol was not given. ADON stated RN 1 did not follow the facility's P&P of notifying the doctor of Resident's low BP and HR and that Resident 1 did not receive the Bisoprolol. ADON stated this placed the resident at risk for delayed care, a change in condition that could result in paramedics (persons trained to give emergency medical care to injured or ill people outside of a hospital setting) being called, hospitalization, and even death.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HOLLENBECK PALMS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.