Holliswood Center for Rehabilitation and Healthcar

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure that a resident was able to exercise their autonomy regarding choices that are important to their life. This is evident in one out of seven residents sampled. Specifically, on 02/15/2026 at 5:00 PM, Resident #1 who was alert and oriented times three, attempted to leave the dining room and Certified Nursing Assistant #1 stood in front of their wheelchair and placed both their hands on the armrests of the wheelchair preventing Resident #1 from leaving the dining room.

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure that residents are free from physical abuse. This was evident for one of seven residents (Resident #1) sampled for abuse. Specifically, on 04/08/2026, Resident #7 reported to Registered Nurse Supervisor #7 that because they refused to take their medications, Licensed Practical Nurse #7 pushed them in their chest causing them to fall on the floor on 04/08/2026 at approximately 5:15 AM. Resident #7 was assessed by Registered Nurse Supervisor #7 with no visible injuries.

Inspectors wroteBased on observation, record review, and interviews conducted during a Survey (2804872), the facility failed to provide adequate supervision to a resident to prevent an accident. This was evident in one out of two residents (Resident #2) sampled for accidents. Specifically, Resident #2 was left unsupervised in the shower room by Certified Nursing Assistant #2 on 03/15/2026 at 4:20 AM. Resident #2 sustained a raised area on the right side of their forehead with active bleeding. Pain medication was administered, and the resident was transferred to the hospital on [DATE] at 5:40 Am and returned to the facility same day at 12:05 PM.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 04/17/2024 to 04/24/2024, the facility did not ensure that infection control prevention practices and procedures were maintained. This was evident for 2 (Resident #276 and #127) of 38 total sampled residents. Specifically, 1) Enhanced Barrier Precautions were not maintained during Foley catheter care for Resident #276, and 2) Enhanced Barrier Precautions were not maintained for gastrostomy tube medication administrations for Resident #127.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from on 04/17/2024 to 04/24/2024, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit 4) of 5 resident units. Specifically, Unit 4 was observed with 1.) furniture heavily worn and in disrepair. 2.) torn and/or stained window curtains. 3.) stained privacy curtains. 4.) broken and chipped ceiling plaster. Torn room wallpaper. 5.) frame of room light fixture in disrepair. 6.) holes in walls/bathroom door. 7.) heavily stained and dirty toilet bowel. 8.) heavily stained, rusty, and dirty room commode. 9.) wheelchair with torn right-side armrest and layered dirt to the metal parts and wheel spokes. 10.) thick, orange-colored streaks of rust stains in the shower room stall. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00331574) survey from 4/17/2024 to 4/24/2024, the facility did not ensure that a resident received quality of care. This was evident for 1 (Resident #266) of 38 total sampled residents. Specifically, Resident #266 did not receive assessment by a qualified Registered Nurse following an injury of unknown origin and a fall.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure a resident received adequate supervision to prevent accident hazards. This was evident for 1 (Resident #104) of 38 total sampled residents. Specifically, Resident #104's comprehensive care plan related to falls was not reviewed and revised to include supervision to prevent further accidents.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00331574) survey from 4/17/2024 to 4/24/2024, the facility did not ensure licensed nurses had the competencies and skills necessary to care for a resident's needs. This was evident for 1 (Resident #266) of 38 total sampled residents. Specifically, Resident #266 did not receive assessment by a qualified Registered Nurse following an injury of unknown origin and a fall.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification and abbreviated survey (NY# 00291493) from 02/23/2022 through 03/03/2022, the facility did not ensure that each resident remained free from physical restraints not required to treat the resident's medical symptoms. This was evident for 11 of 12 residents sampled for Physical Restraints (Resident #s 199, 260, 113, 191, 126, 110, 55, 295, 63, 503, and 157). Specifically, Resident #260 and Resident #113 had bilateral half SR ordered as enablers. The residents had severely impaired cognition, required extensive assistance with bed mobility and transfers, and the half SR were not identified as a restraint. There was no medical justification, restraint assessment, care plan, or evidence of alternatives attempted before using the bilateral half SR. [...]

Inspectors wrote2) On 02/23/22 at 10:06 AM, in room [ROOM NUMBER], five holes approximately the size of dimes were observed in the wall next to the paper towel dispenser. On 02/24/22 at 08:41 AM, 02/28/22 at 11:31 AM, 03/01/22 at 09:44 AM, and 03/02/22 at 09:37 AM the same was observed. On 03/02/22 at 12:47 PM, the Maintenance Worker (MW) # 1 was interviewed. MW #1 stated they were not regularly assigned to the 5th floor. The MW assigned to the floor will make daily rounds and report back to the supervisor with any issues. MW #1 stated the supervisor makes rounds on all the units once a week. The State Agent (SA) showed MW #1 the holes in the wall in room [ROOM NUMBER]. MW #1 was not aware of the holes in the wall in room [ROOM NUMBER]. MW #1 stated the soap dispenser was missing from the wall. MW #1 stated they will replace the soap dispenser. [...]

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification and Complaint survey, the facility did not ensure procured food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. Specifically, expired thickened apple juice stored in the kitchen storeroom was not discarded on or before the expiration date. This was evident during the Kitchen Observation facility task.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey the facility did not ensure a quality assurance and performance improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies. Specifically, the facility had repeat deficiencies from the previous recertification surveys (May 2019 & December 2017) in the areas of right to be free from physical restraints (F604) and care plan timing and revision (657). There was no evidence there was a QAPI plan in place to meet the specific needs of the facility.

Inspectors wroteBased on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that it maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) multiple residents were not offered hand hygiene before lunch and dinner meals on the 2nd Floor unit. (2) Multiple residents receiving oxygen therapy were noted with oxygen tubing touching the floor on multiple occasions and oxygen tubing was observed being stored without a plastic covering wrapped around the top of the oxygen concentrator on the 4th floor. This was evident for the dining observations on the 2nd floor and a random infection control observations on 2 out of 6 resident units. (Unit 2 and Unit 4)

Inspectors wroteBased on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that a resident's designated representative was informed of a change in medication. Specifically, an antipsychotic medication was initiated, discontinued, and restarted without documented evidence the family was made aware. This was evident for 1 of 1 residents reviewed for Notification of Change (Resident #272). The finding is: The facility policy for notification dated 4/2019 documented: except in a medical emergency, the facility must consult with the resident immediately if the resident is competent and notify the residents physician and designated representative when there is: a need to alter treatment significantly (to commence a new form of treatment). [...]

Inspectors wroteBased on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure person-centered care plans with measurable objectives and timeframes to meet a resident's medical and nursing needs identified in the comprehensive assessment were developed. Specifically, (1) a comprehensive care plan (CCP) was not developed and implemented to address care needs for a resident's tracheostomy/repsiratory care (Resident #451), and (2) a resident's CCP did not include interventions to address the use of a BiLevel Positive Airway Pressure (BIPAP) machine (Resident #286). This was evident for 2 out of 2 residents reviewed for care planning out of a total of 38 residents (Resident #451 and #286).

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey, the facility did not ensure that the comprehensive care plans were reviewed and/or revised after each assessment and as needed. Specifically, multiple care plans for resident #230 were not reviewed and/or revised. This was evident for 1 of 1 reviewed for tube feeding out of a total of 36 residents investigated.

Inspectors wroteBased on observation, record reviews, and staff interviews during the Recertification Survey the facility did not ensure residents were free from unnecessary antipsychotic medications. Specifically, a resident who had no prior history with mental illness of Schizophrenia was diagnosed and treated with the antipsychotic medication Seroquel. This was evident for 1 of 5 residents reviewed for Unnecessary Medications. (Resident #272).

Inspectors wroteBased on observation, record reviews and interviews during the recertification and the abbreviated survey the facility did not ensure that the residents environment were free of abuse. Specifically: 1) (Complaint #NY00233088) On 1/24/19 resident Resident #211 with impaired cognition had physically assaulted his roommate Resident # 25. 2) (Complaint #NY00232253) Resident #141 with moderate impairment of cognition and impulsive behaviors physically assaulted two residents on two separate occasions. A) On 1/9/19 Resident #141 struck Resident #73 on his right side of head with an ensure container causing a superficial cut. B) On 4/9/19 Resident #141 pushed Resident #27 which resulted the resident falling. This was evident for 3 of 5 residents investigated for abuse. Res#25, Res#73, Res#27. [...]

Inspectors wroteBased on observations, record review, and staff interviews conducted during the recertification survey, the facility failed to ensure that the residents are free from any physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Specifically, The SA (State Agency Surveyor) observed Resident #122 on multiple occasions seated in a wheelchair with a seatbelt buckled in at the waist. The resident's most recent MDS (Minimum Data Set 30) assessment documented that restraints were not in use for this resident. There was no medical justification documented in the resident's record requiring the use of a seatbelt. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey, the facility did not review the resident's care plan after each assessment and revise based on changing goals, and the needs of the response to current interventions. Specifically, the CCP for the resident identified the use of a seatbelt as a physical restraint to prevent resident from sliding out of chair and attempting to stand and walk unassisted. The CCP was not revised since 2016. Since then the Physician/Nurse Practitioner's (NP) ordered that the seatbelt be discontinued on three occasions. In addition the CCP did not document the medical justification for the continued use of the seatbelt, or resident's change in behavior.