A list of the most recent deficiencies for Hollenbeck Palms. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Meet other general requirements that are deficient. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-27 | 2023-12-14 | N |
| 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. | Health | 2023-11-19 | 2023-12-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-19 | 2023-12-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-19 | 2023-12-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-19 | 2023-12-13 | N |
| 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. | Health | 2023-11-19 | 2023-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-19 | 2023-12-13 | N |
| 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. | Health | 2023-11-19 | 2023-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-19 | 2023-12-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-19 | 2023-12-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-16 | 2023-08-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-16 | 2023-08-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2022-12-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-29 | 2022-08-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-28 | 2022-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-08 | 2019-06-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-04-08 | 2019-06-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-08 | 2019-06-26 | N |
| 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. | Health | 2019-04-08 | 2019-06-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-08 | 2019-05-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-08 | 2019-05-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-08 | 2019-05-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-08 | 2019-05-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-08 | 2019-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-05-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-12 | 2019-05-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-12 | 2019-05-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-04-12 | 2019-05-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-12 | 2019-05-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-12 | 2019-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-12 | 2019-05-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-12 | 2019-05-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-03-25 | 2018-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-25 | 2018-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-25 | 2018-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-25 | 2018-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-25 | 2018-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-25 | 2018-04-19 | N |
| 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. | Health | 2018-03-25 | 2018-04-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-03-25 | 2018-04-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-25 | 2018-04-19 | N |
| 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. | Health | 2018-03-25 | 2018-04-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-25 | 2018-04-19 | N |
| 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. | Health | 2018-03-25 | 2018-04-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-03-25 | 2018-04-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-03-25 | 2018-04-19 | N |
| 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. | Health | 2018-03-25 | 2018-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-25 | 2018-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-25 | 2018-04-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-03-25 | 2018-04-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
