A Holly Patterson Extended Care Facility

In the surveyor’s words

From the most serious findings on record at A Holly Patterson Extended Care Facility, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 9, 2022

  Based on record reviews and staff interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022 the facility failed to ensure that the resident's environment was free of accident hazards for one (Resident #220) of 4 residents reviewed for accidents. Specifically, Resident #220 with a known history of Polysubstance abuse, was not supervised to prevent the availability of non-prescribed illicit drug usage within the facility. Resident #220 was readmitted to the facility on [DATE]. A Psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The current facility did not develop care plan interventions to monitor and supervise the resident for substance abuse. […]

• Immediate jeopardy, patternF740Mar 9, 2022

  Based on observation, interviews and record review during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, the facility failed to ensure each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Resident #220 was admitted to the facility with a known history of illicit drug abuse. […]

• Immediate jeopardy, isolatedF689Jun 30, 2026

  Based on observations, record review, and staff interviews, the facility failed to provide adequate supervision and a safe environment for each resident. This was identified for one (Resident #3) of five residents reviewed for elopement. Specifically, Resident #3 who had severe cognitive impairment, exit seeking behaviors, and was at high risk for elopement, exited their fourth-floor room through a window and fell to a second-floor patio (awning roof) sustaining multiple fractures (broken bones) on 03/03/2026. Upon the resident's return from the hospital to the facility on [DATE], the resident was placed back onto the fourth floor and continued to have access to the windows in their room. […]

• Immediate jeopardy, isolatedF600May 23, 2025

  Based on observations, record review, and staff interviews during an abbreviated survey (NY00380105), the facility failed to prevent and protect an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, Certified Nursing Assistant #1 was observed on facility surveillance video restraining both hands of Resident #1 and hitting them in the head two (2) times. Using the reasonable person concept, this resulted in actual psychosocial harm that was Immediate Jeopardy. The findings are: Resident #1 had a medical diagnosis including dementia, hyperlipidemia, and hypertension. […]

• Immediate jeopardy, isolatedF607May 23, 2025

  Based on record review, and staff interview during an abbreviated survey (NY00380105), the facility failed to implement Abuse/Neglect policies to prevent, protect and report an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, the facility failed to protect Resident #1 from Certified Nursing Assistant #1 who was observed restraining both hands of Resident #1 and hitting them in the head. This incident was observed by Certified Nursing Assistants #2 and #3 who were in the hallway at the time of the incident and did not identify, correct, intervene or report the occurrence of abuse. […]