Inspection Reports for
Highland Rehabilitation and Nursing Center
120 Highland Avenue, Middletown, NY, 10940
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Inspection Report — Feb 6, 2026
Complaint Investigation State
Date: Feb 6, 2026
Visit Reason
State-compiled facility profile showing 5 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 57 complaints about this facility; 9 led to on-site inspections. The facility received 64.9 complaints per 100 beds versus a statewide rate of 57.4, with 20 citations resulting from those complaints.
Findings
Across 5 inspections, 3 resulted in citations totaling 57, including 48 standard health and 9 life safety code citations. The facility had multiple minor potential harm deficiencies but no enforcement actions were recorded.
Citations (38)
Accuracy Of Assessments: Standard Health Citation — quality of care with isolated minor potential harm.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with isolated minor potential harm.
Notify Of Changes (injury/decline/room, Etc.): Standard Health Citation — quality of care with isolated minor potential harm.
ADL Care Provided For Dependent Residents: Standard Health Citation — quality of care with pattern minor potential harm.
Care Plan Timing And Revision: Standard Health Citation — quality of care with isolated minor potential harm.
Covid-19 Immunization: Standard Health Citation — quality of care with pattern minor potential harm.
Department Criminal History Review: Standard Health Citation — quality of care with no harm potential.
Facility Assessment: Standard Health Citation — quality of care with pattern minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with pattern minor potential harm.
Free From Misappropriation/exploitation: Standard Health Citation — quality of care with isolated minor potential harm.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with isolated minor potential harm.
Free Of Medication Error Rts 5 Prcnt Or More: Standard Health Citation — quality of care with isolated minor potential harm.
Infection Control: Standard Health Citation — quality of care with pattern minor potential harm.
Influenza And Pneumococcal Immunizations: Standard Health Citation — quality of care with isolated minor potential harm.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with isolated minor potential harm.
Provided Diet Meets Needs Of Each Resident: Standard Health Citation — quality of care with pattern minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with pattern minor potential harm.
Self-determination: Standard Health Citation — quality of care with isolated minor potential harm.
Treatment/svcs To Prevent/heal Pressure Ulcer: Standard Health Citation — quality of care with isolated minor potential harm.
Building Construction Type And Height: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Corridor - Doors: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Discharge From Exits: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Hvac: Life Safety Code Citation — NFPA requirements with widespread minor potential harm.
Maintenance, Inspection & Testing - Doors: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with widespread minor potential harm.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Assistive Devices - Eating Equipment/utensils: Standard Health Citation — quality of care with isolated minor potential harm.
Care Plan Timing And Revision: Standard Health Citation — quality of care with isolated minor potential harm.
Essential Equipment, Safe Operating Condition: Standard Health Citation — quality of care with pattern minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with pattern minor potential harm.
Medicaid/medicare Coverage/liability Notice: Standard Health Citation — quality of care with isolated minor potential harm.
Notice Of Bed Hold Policy Before/upon Trnsfr: Standard Health Citation — quality of care with isolated minor potential harm.
Notice Requirements Before Transfer/discharge: Standard Health Citation — quality of care with isolated minor potential harm.
Reasonable Accommodations Needs/preferences: Standard Health Citation — quality of care with isolated minor potential harm.
Safe/functional/sanitary/comfortable Environ: Standard Health Citation — quality of care with isolated minor potential harm.
Treatment/svcs To Prevent/heal Pressure Ulcer: Standard Health Citation — quality of care with isolated minor potential harm.
Report Facts
Inspections on page: 5
Total citations: 57
Inspections with violations: 3
Inspections without violations: 2
Total complaints: 57
On-site complaint inspections: 9
Citations from complaints: 20
Enforcement actions: 0
Inspection Report — Jul 3, 2025
Annual Inspection CMS
Date: Jul 3, 2025
Visit Reason
Recertification and abbreviated surveys conducted to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident rights, environment cleanliness, protection from misappropriation, care planning, activities of daily living assistance, pressure ulcer care, fall prevention, medication administration, medication storage, nutrition and meal service, facility-wide assessment, and vaccination documentation.
Citations (13)
F 0561: The facility restricted Resident #25's visitation rights based on family and administrator wishes despite the resident's desire to see their friend.
F 0584: Unit 2 was observed with poor environmental cleanliness including peeling wallpaper, dirty floors, soiled wheelchairs, and moldy, unlabeled food in the dining room refrigerator.
F 0602: Resident #5 experienced misappropriation of property including staff eating their personal food and diversion of income to the facility without consent.
F 0657: Comprehensive Care Plans were not reviewed or revised after incidents for Residents #345 and #363, including falls and episodes of aggression.
F 0677: Residents #54, #19, and #27 did not consistently receive necessary assistance with activities of daily living, resulting in poor hygiene and unmet mobility needs.
F 0686: Resident #19's pressure ulcer care was inadequate with delayed implementation of an air mattress, incomplete assessments, and lack of pain management.
F 0689: Resident #67 had multiple unwitnessed falls with incomplete investigations and lack of updated care plans or interventions to prevent recurrence.
F 0759: Medication error rate exceeded 5% with improper administration of inhalers and eye drops to Resident #22 without appropriate timing or rinsing.
F 0761: Expired and undated medications and biologicals were found in medication rooms and carts, and some vaccines were improperly stored in freezer sections.
F 0800: Unit 2 residents were not consistently served all meal items per physician orders and meal tickets, including missing desserts and nutritional supplements; cold and hot food items were not always held at safe temperatures.
F 0812: Unit 2 dining room refrigerator contained unlabeled, undated, and spoiled food items including moldy and foul-smelling substances; staff food was improperly stored in resident refrigerators.
F 0838: Facility-wide assessment was incomplete, lacking documentation of staff training, unit-specific staffing needs, and plans for recruitment and retention of qualified medical practitioners.
F 0887: Resident #25 and multiple staff members lacked documented COVID-19 vaccination status and education; facility did not ensure vaccination offers and documentation.
Report Facts
Medication error rate: 10
Expired syringes: 29
Fall risk score: 15
Fall risk score: 24
Pressure ulcer size: 48.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in medication administration errors and food refrigerator contamination |
| Certified Nurse Aide #38 | Certified Nurse Aide | Named in observations of resident nail care deficiencies and food refrigerator contamination |
| Director of Nursing | Director of Nursing | Interviewed regarding facility assessment, vaccination offers, and fall prevention |
| Assistant Director of Nursing | Assistant Director of Nursing and Infection Preventionist | Interviewed regarding vaccination documentation and infection control |
| Registered Nurse Unit Manager #5 | Registered Nurse Unit Manager | Interviewed regarding medication storage and environmental cleanliness |
| Dietary Aide #40 | Dietary Aide | Interviewed regarding meal service and food temperature monitoring |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed regarding meal service and resident assistance |
Inspection Report — Aug 25, 2023
Annual Inspection CMS
Date: Aug 25, 2023
Visit Reason
The inspection was a recertification survey conducted from 8/21/23 to 8/25/23 to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including call bell accessibility, notification procedures for Medicare non-coverage and hospital transfers, care plan revisions, provision of adaptive eating equipment, food safety and hygiene practices, dishwasher sanitizer monitoring, and maintenance of resident care equipment cleanliness.
Citations (9)
F 0558: The facility failed to ensure the call bell system was accessible for 1 of 3 residents reviewed, with the call bell repeatedly found out of reach for Resident #5.
F 0582: The facility failed to provide appropriate Notice of Medicare Non-Coverage to Resident #74 or their representative at least two calendar days before Medicare covered services ended.
F 0623: The facility did not notify residents or their representatives in writing of transfer/discharge reasons or notify the Ombudsman for Residents #11 and #91.
F 0625: The facility failed to notify Residents #11 and #91 or their representatives in writing of the facility Bed Hold Policy upon hospital transfer.
F 0657: The facility did not review and revise the comprehensive care plan for Resident #84 after Foley catheter removal to address urinary incontinence care.
F 0810: The facility failed to provide special eating equipment and utensils as ordered for Resident #45, who was observed eating without the required divided scoop plate and bendable utensils.
F 0812: The facility did not ensure food was stored and served at safe temperatures and kitchen staff did not consistently use hygienic practices including beard restraints and glove use.
F 0908: The facility used a low temperature dishwasher with chemical sanitizer but failed to monitor sanitizer concentration as required for safe operation.
F 0921: The facility did not maintain a safe, clean, and comfortable environment; Resident #42's wheelchair was heavily soiled with a ripped cushion, and Resident #69's tube feeding equipment was heavily soiled and uncleaned.
Report Facts
Food temperature: 52
Food temperature: 63.9
Food temperature: 58.1
Bladder scan volume: 87
Bladder scan volume: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS coordinator | Named in relation to failure to provide Notice of Medicare Non-Coverage to Resident #74. | |
| Director of Finance | Named in relation to sending Medicare Non-Coverage notices without documented confirmation. | |
| Administrator | Named in relation to oversight of notification and bed hold policy deficiencies. | |
| Registered Nurse Unit Manager (RNUM) #1 | Named in relation to call bell accessibility and adaptive equipment provision. | |
| Nurse Practitioner (NP) | Named in relation to Resident #84 Foley catheter discontinuation and care plan review. | |
| Food Service Director | Named in relation to food service safety, adaptive equipment meal ticket discrepancies, and kitchen hygiene. | |
| Director of Rehab | Named in relation to adaptive equipment issuance for Resident #45. | |
| Registered Nurse Manager | Named in relation to care plan review for Resident #84. | |
| Director of Maintenance/Housekeeping (DMH) | Named in relation to cleaning and maintenance of resident care equipment. |
Inspection Report — Jan 31, 2020
Annual Inspection CMS
Date: Jan 31, 2020
Visit Reason
The inspection was a recertification survey and abbreviated survey to assess compliance with regulatory requirements for Highland Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including resident dignity during wound care, failure to provide written bed-hold notices, incomplete and non-person-centered care plans, failure to prevent decline in resident mobility and ambulation, inadequate pressure ulcer care and prevention, improper documentation of care, inadequate infection control practices, and inconsistent dialysis and respiratory care.
Citations (12)
F 0550: The facility did not ensure resident dignity during a wound care procedure when a resident was left exposed with privacy curtain partially open and door wide open.
F 0625: The facility failed to provide written notice to residents or their representatives about the bed-hold policy during hospitalizations for 3 residents.
F 0656: The facility did not develop person-centered care plans with measurable goals and appropriate interventions for residents with positioning, mobility, and pressure ulcer needs.
F 0657: The facility did not evaluate or revise care plans timely to reflect residents' current status or effectiveness of interventions for activities of daily living and nutrition.
F 0676: The facility failed to provide appropriate care to prevent decline in ambulation for a resident after discharge from rehabilitation services.
F 0686: The facility did not provide appropriate pressure ulcer care or prevent new ulcers for residents, including failure to implement heel booties and offload pressure areas.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion and positioning devices for residents with contractures and mobility limitations.
F 0690: The facility did not provide appropriate care to address decline in bowel and bladder continence for a resident, including lack of assessment and care plan revision.
F 0695: The facility did not provide appropriate respiratory care for a resident, including lack of oxygen saturation monitoring and unclear physician orders for oxygen administration.
F 0698: The facility failed to provide consistent pre and post dialysis assessments for a resident receiving dialysis.
F 0842: The facility did not accurately document resident care; a resident who remained in bed was documented as transferred, and a resident not wearing prescribed positioning devices was documented as wearing them.
F 0880: The facility failed to implement infection prevention and control practices during wound care, including failure to perform hand hygiene and cross contamination of wounds.
Report Facts
Residents reviewed for skin integrity: 3
Residents reviewed for positioning and mobility: 3
Residents reviewed for activities of daily living: 3
Residents reviewed for dialysis: 1
Residents reviewed for respiratory care: 1
Residents reviewed for bowel and bladder incontinence: 3
Deficiency counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control and wound care deficiencies for improper hand hygiene and wound care procedure |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding wound care and resident heel booties |
| LPN #3 | Licensed Practical Nurse | Interviewed about resident positioning devices and documentation |
| RN #1 | Registered Nurse Manager | Interviewed about wound care and resident positioning devices |
| RN #2 | Registered Nurse Manager | Interviewed about care plan updates, resident ambulation, and documentation |
| CNA #2 | Certified Nursing Assistant | Interviewed about resident care and use of positioning devices |
| CNA #3 | Certified Nursing Assistant | Interviewed about resident transfers and documentation |
| CNA #4 | Certified Nursing Assistant | Interviewed about resident toileting and ambulation |
| CNA #5 | Certified Nursing Assistant | Interviewed about resident toileting and ambulation |
| CNA #7 | Certified Nursing Assistant | Interviewed about resident shower and skin checks |
| Rehabilitation Director | Interviewed about resident ambulation and therapy discharge | |
| PT | Physical Therapist | Interviewed about resident ambulation decline |
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