Health inspection·January 28, 2026

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility (Facility 1) failed to clarify and continue the therapeutic diet (a specially prescribed meal plan that modifies normal eating to treat a medical condition, managing nutrients, calories, textures, or allergies for health improvement, often prescribed by doctors and planned by dietitians for things like diabetes, heart disease, kidney issues, or post-surgery recovery) for one (1) of four (4) sampled residents (Resident 1) upon admission to the facility on 9/19/2025. This failure resulted in Resident 1 receiving the incorrect diet for three (3) days (9/19/2025 to 9/23/2025) upon admission to the facility.During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic (long-term) congestive heart failure (a condition where the heart muscles become too weak or stiff to pump blood efficiently causing fluid to back up in the lungs and body) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 9/25/2025, the MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive (ability to think, remember, and reason) skills for daily decision making. The MDS indicated, Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two [2] or more helpers is required for the resident to complete the activity) with walking 50 feet, going from lying down to sitting on the side of the bed, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and eating. It also indicated, Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with walking 10 feet, chair/bed-to-chair transfers and going from sitting to standing.During a concurrent interview and record review on 1/27/2026 at 1:25 PM with Assistant Director of Nursing (ADON), Resident 1's Order Summary Report dated 9/19/2025 was reviewed. Resident 1's Order Summary Report indicated an order from 9/19/2025 at 2:36 PM indicating the order confirmed by ADON for pureed diet (foods blended, whipped or mashed into a smooth, thick, pudding-like consistency that requires no chewing), pureed texture, thin liquids consistency (the consumption of liquids that have the same consistency as water an flow quickly requiring no thickeners to be added). ADON stated when she received report from Resident 1's previous skilled nursing facility (SNF 2), the report she received from an unknown staff member was that Resident 1 was on a pureed diet. During an interview on 1/27/2026 at 3:45 PM with SNF 2's Registered Nurse (RN), RN stated Resident 1's diet upon discharge from their facility was fortified (foods that have vitamins and minerals added to them that are not naturally present or were lost during processing and aims to improve nutritional quality, boost nutrient density), soft and bite sized texture and thin liquids.During an interview on 1/27/2026 at 4:11 PM with ADON, ADON stated on 9/19/2025 when she was receiving report from an (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055115 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)