ElderGrade

Inspection citations at Hollenbeck Palms

39 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 2 0
2025 9 0
2024 17 1
2023 11 0
D February 24, 2026 Tag F0684 Complaint investigation Corrected Mar 2026

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D January 28, 2026 Tag F0808 Complaint investigation Corrected Feb 2026

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

No actual harm, potential for more than minimal harm

D December 12, 2025 Tag F0880 Corrected Dec 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D December 12, 2025 Tag F0694 Corrected Dec 2025

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

D December 12, 2025 Tag F0677 Corrected Dec 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D December 12, 2025 Tag F0657 Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D December 12, 2025 Tag F0605 Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

No actual harm, potential for more than minimal harm

D December 12, 2025 Tag F0550 Corrected Dec 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E December 12, 2025 Tag F0919 Corrected Dec 2025

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

E December 12, 2025 Tag F0812 Corrected Dec 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E December 12, 2025 Tag F0686 Corrected Dec 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

B October 25, 2024 Tag F0732 Corrected Nov 2024

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D October 25, 2024 Tag F0760 Corrected Nov 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D October 25, 2024 Tag F0755 Corrected Nov 2024

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D October 25, 2024 Tag F0695 Corrected Nov 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D October 25, 2024 Tag F0677 Corrected Nov 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D October 25, 2024 Tag F0604 Corrected Nov 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D October 25, 2024 Tag F0578 Corrected Nov 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 25, 2024 Tag F0550 Corrected Nov 2024

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E October 25, 2024 Tag F0814 Corrected Nov 2024

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

No actual harm, potential for more than minimal harm

E October 25, 2024 Tag F0812 Corrected Nov 2024

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E October 25, 2024 Tag F0759 Corrected Nov 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

E October 25, 2024 Tag F0689 Corrected Nov 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

F October 25, 2024 Tag F0880 Corrected Nov 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D August 20, 2024 Tag F0656 Complaint investigation Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D August 20, 2024 Tag F0604 Complaint investigation Corrected Sep 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

E August 20, 2024 Tag F0758 Complaint investigation Corrected Sep 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

G August 20, 2024 Tag F0689 Complaint investigation Corrected Sep 2024

Quality of Life and Care Deficiencies

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

Actual harm to a resident

D November 19, 2023 Tag F0761 Corrected Dec 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D November 19, 2023 Tag F0677 Corrected Dec 2023

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D November 19, 2023 Tag F0607 Complaint investigation Corrected Dec 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D November 19, 2023 Tag F0580 Corrected Dec 2023

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D November 19, 2023 Tag F0578 Corrected Dec 2023

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E November 19, 2023 Tag F0880 Corrected Dec 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E November 19, 2023 Tag F0849 Corrected Dec 2023

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

E November 19, 2023 Tag F0812 Corrected Dec 2023

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E November 19, 2023 Tag F0686 Corrected Dec 2023

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

F July 16, 2023 Tag F0925 Complaint investigation Corrected Aug 2023

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

F July 16, 2023 Tag F0812 Complaint investigation Corrected Aug 2023

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.