Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holliswood Center For Rehabilitation And Healthcar during CMS and state inspections, most recent first.
A resident with intact cognition and diagnoses including anxiety and stroke-related hemiparesis/hemiplegia was prevented by a CNA from leaving the dining room when the CNA stood in front of the wheelchair and placed both hands on the armrests while telling the resident to stay because they were being monitored for falls. The resident and family later reported the resident was hit or pushed during the interaction, police responded, and the resident was transferred to the hospital for chest pain. The facility's investigation concluded there was no evidence of abuse, neglect, or mistreatment.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident with severely impaired cognition and bathing assistance needs was left alone in a shower room by a CNA during bathing care. The CNA left to get soap after placing the resident in a locked shower chair, and the resident was later found standing with a bump and bleeding on the forehead. The resident was sent to the hospital for a CT scan and later returned to the facility.
The facility did not maintain Enhanced Barrier Precautions for two residents, one with a Foley catheter and another with a gastrostomy tube. An LPN providing catheter care and another administering medication via a gastrostomy tube failed to don gowns as required. Staff were unaware of the protocol, and the facility was in the process of implementing the precautions.
A resident with Parkinson's disease and dementia did not receive an assessment by a qualified RN following an injury and a fall. An LPN, who was not licensed as an RN, conducted the assessments and reported the incidents, leading to a deficiency in care.
A resident with Parkinson's disease and dementia did not receive an assessment by a qualified RN following an injury and a fall. An LPN, who was not qualified to act as an RN, conducted the assessment and reported the incident, but there was no documented evidence of an RN assessment as required. The DON was unaware of the LPN's lack of a permit to practice as an RN.
A survey revealed that Unit 4 in the facility failed to provide a safe, clean, and homelike environment for residents. Observations included worn and damaged furniture, stained and torn curtains, broken ceiling plaster, and dirty toilets and commodes. Despite established cleaning routines and reporting systems, these deficiencies indicate a failure to maintain expected standards.
A resident with schizophrenia and acute kidney failure experienced multiple falls, but the facility failed to review and revise the care plan as required. Despite having interventions in place, the care plan was not updated after the falls, and staff interviews revealed a lack of adherence to the facility's policies.
Resident Prevented From Leaving Dining Room
Penalty
Summary
The facility failed to ensure that a resident was able to exercise autonomy regarding choices important to their life. On 02/15/2026 at about 5:00 PM, Resident #1, who was alert and oriented times three and had intact cognition on the Minimum Data Set dated 02/04/2026, attempted to leave the dining room in a wheelchair. Certified Nursing Assistant #1 stood in front of the wheelchair and placed both hands on the armrests, preventing the resident from leaving the dining room while explaining that the resident should remain there because they were being monitored and were at risk of falling. Resident #1 was admitted with diagnoses including anxiety and cerebral infarction with hemiparesis and hemiplegia. The care plan documented that the resident was able to make leisure preferences known, including watching television, reading, and listening to music. During the interaction, Certified Nursing Assistant #1 stated the resident refused to return to the dining room, and the CNA positioned themself in front of the wheelchair and pushed the chair back while keeping hands on the armrests. The CNA reported that the resident then hit and kicked them in the chest area, and the CNA stated they were trying to keep the resident in the dining room until the resident's family came. The investigation record also included reports from the resident's family that the resident said they were hit on the right chest and right knee by the CNA. A nursing note documented that police responded and the resident was transferred to the hospital for chest pain. Later interviews reflected that the resident reported being pushed back into the wheelchair very hard when asking to be put back in bed because sitting in the chair hurt their hips and legs. The facility's investigation concluded there was no evidence of abuse, neglect, or mistreatment, while the Assistant DON stated staff were trained on resident rights and that residents have the right to move about freely.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Supervise Resident During Shower Care
Penalty
Summary
The facility failed to provide adequate supervision to a resident during bathing care. Resident #2 had diagnoses including Bipolar Disorder, Dementia, and Major Depressive Disorder, and the Minimum Data Set documented severely impaired cognition and the need for partial/moderate assistance with bathing and shower transfers. The resident’s care plan also identified the resident as at risk for falls and required one-person physical assistance for shower/tub transfer. On 03/15/2026 at about 4:20 AM, a CNA brought the resident to the shower/bathroom after observing a bowel movement. The CNA reported that the resident was placed in a locked shower chair and then left alone in the shower room to get soap for the dispenser. When the CNA returned, the resident was standing in the shower room and had a bump on the right side of the forehead. The CNA stated the resident should not have been left unsupervised in the shower room. A nursing assessment documented swelling to the right forehead with a small skin opening and scant sanguineous drainage. The resident was transferred to the hospital for a CT scan and later returned to the facility the same day. Interviews with the LPN, RN supervisor, NP, and DON confirmed that the resident was left unattended in the shower room and that the incident occurred during bathing care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection control prevention practices and procedures, specifically Enhanced Barrier Precautions, for two residents during the recertification survey. Resident #276, who had a diagnosis of obstructive uropathy and non-Alzheimer's dementia, was observed receiving Foley catheter care from an LPN who did not don a gown as required by the facility's infection control policy. The LPN was unaware of the need to wear a gown for Enhanced Barrier Precautions during Foley catheter care, despite having been inserviced on this requirement earlier that day. Similarly, Resident #127, with diagnoses of dysphagia and gastrostomy status, was administered medication via a gastrostomy tube by another LPN who also failed to don a gown. This LPN was not aware of the Enhanced Barrier Precautions protocol and did not know that a gown was required for administering medications to residents with a gastrostomy tube. Interviews with the facility's nursing staff, including the newly hired Infection Preventionist and the Director of Nursing, revealed that the facility had not fully implemented Enhanced Barrier Precautions and was in the process of inservicing staff and awaiting supplies to comply with the protocol.
Failure to Provide Qualified RN Assessment After Resident Injury and Fall
Penalty
Summary
The facility did not ensure that Resident #266 received quality care following an injury of unknown origin and a fall. Resident #266, who had diagnoses of Parkinson's disease and dementia, was found with swelling and discoloration to their left-hand fingers and later was found lying on the floor. Both incidents were assessed by Licensed Practical Nurse (LPN) #6, who was acting as the Supervisor. However, LPN #6 was not a qualified Registered Nurse and had failed the Registered Nurse licensing exam. Despite this, LPN #6 assessed the resident, contacted the Nurse Practitioner, and initiated an incident report and an x-ray order. The Director of Nursing (DON) believed that LPN #6 could practice in the capacity of a Registered Nurse because they held an Associate's degree in Nursing. However, the DON was unaware that LPN #6 did not have a permit to practice as a Registered Nurse in New York State. This led to a failure in providing the required assessment by a qualified Registered Nurse for Resident #266 following the injury and fall, as mandated by the facility's policy and state regulations.
Failure to Ensure Competent Nursing Assessment
Penalty
Summary
The facility did not ensure that licensed nurses had the necessary competencies and skills to care for a resident's needs. This was evident in the case of a resident with Parkinson's disease and dementia who did not receive an assessment by a qualified Registered Nurse following an injury of unknown origin and a fall. The facility's policy required that incidents and injuries be reported to the on-duty Supervisor, but the assessment was conducted by an LPN who was not qualified to act as an RN. The LPN assessed the resident, contacted the Nurse Practitioner, and initiated an incident report, but there was no documented evidence of an RN assessment as required. Interviews revealed that the LPN who conducted the assessment was designated as a Supervisor and was practicing in the capacity of an RN despite not having passed the RN licensing exam or having a permit to practice as an RN in New York State. The Director of Nursing believed the LPN could practice as an RN because they held an Associate's degree in Nursing, but was unaware of the LPN's lack of a permit. This oversight led to the resident not receiving the appropriate level of care as mandated by regulations.
Deficiencies in Maintaining a Homelike Environment on Unit 4
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on Unit 4, as observed during a recertification survey. The survey revealed multiple deficiencies, including heavily worn and damaged furniture, torn and stained window and privacy curtains, broken and chipped ceiling plaster, and torn room wallpaper. Additionally, there were issues with room light fixtures, holes in walls and bathroom doors, and heavily stained and dirty toilets and commodes. A wheelchair was found with a torn armrest and layered dirt, and the shower room had rust stains and a dirty ceiling tile. The nurse's front desk area was also noted to be layered with dirt and dust, and faucet handles were loose and rusty. Interviews with staff, including a housekeeper and the Director of Housekeeping, indicated that there were established routines and systems in place for cleaning and reporting maintenance issues. However, the observations made during the survey suggest that these systems were not effectively implemented or followed. The housekeeper assigned to Unit 4 stated that they reported issues with curtains and repairs to the appropriate departments, while the Director of Housekeeping mentioned conducting daily environmental rounds to ensure cleanliness and safety. Despite these procedures, the deficiencies observed indicate a failure to maintain the expected standards of a homelike environment for residents.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and prevention of accident hazards for a resident, leading to a deficiency. The resident, who had diagnoses of schizophrenia and acute kidney failure, was at risk for falls due to psychoactive drug use, tremors, a history of falls, and unsafe attempts to self-transfer. Despite having a comprehensive care plan that included interventions such as providing a urinal at the bedside, scheduled toileting, and non-skid socks, the care plan was not reviewed or revised after the resident experienced falls on two separate occasions. The facility's policy required that the interdisciplinary care plan be reviewed and revised after a fall event, but there was no documented evidence that this was done for the resident after falls on two consecutive days. Interviews with staff, including a registered nurse and the Director of Nursing, revealed that the care plan was not updated as required. The Director of Nursing could not explain why the care plan was not reviewed or revised following the falls, indicating a lapse in the facility's adherence to its own policies and procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hollis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollis Park Manor Nursing Home | 0 mi | ★★★★★ | 0 | 0 |
| Windsor Park Rehab & Nursing Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Margaret Tietz Center For Nursing Care Inc | 1.4 mi | ★★★★★ | 0 | 0 |
| Highland Care Center | 1.4 mi | ★★★★★ | 10 | 0 |
| Hillside Manor Rehab & Extended Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.