Inspection Reports for
Highland Rehabilitation and Nursing Center
120 Highland Avenue, Middletown, NY, 10940
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
23.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
357% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 3, 2025
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found to have multiple deficiencies including restricting resident visitation rights, inadequate environmental cleanliness, misappropriation of resident property, failure to update comprehensive care plans after incidents, insufficient assistance with activities of daily living, and inadequate supervision to prevent resident falls.
Deficiencies (6)
F 0561: The facility restricted Resident #25's right to receive visitors of their choosing based on family and administrator wishes despite resident's desire to see their friend.
F 0584: Unit 2 was observed with peeling wallpaper, dirty floors, soiled wheelchairs, and strong odors. Resident #5's personal food was taken and eaten by staff from the dining room refrigerator.
F 0602: Resident #5's monthly income was diverted to the facility's bank account without their consent or knowledge, constituting misappropriation of property.
F 0657: Comprehensive care plans were not reviewed or revised after a fall for Resident #345 and after episodes of aggression for Resident #363.
F 0677: Residents #54, #19, and #27 did not consistently receive necessary assistance with activities of daily living, resulting in poor hygiene and lack of mobility support.
F 0689: Resident #67 experienced multiple falls with incomplete investigations and inadequate interventions, including delayed placement of floor mats and insufficient supervision.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Fall risk score: 15
Fall risk score: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Named in misappropriation of Resident #5's food and income findings | |
| Certified Nurse Aide #38 | Named in observations of Resident #54's nail care and hygiene | |
| Director of Nursing | Interviewed regarding care plan updates and abuse reporting | |
| Finance Coordinator | Interviewed regarding Resident #5's income diversion | |
| Administrator | Interviewed regarding visitation restrictions for Resident #25 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 24
Date: Jul 3, 2025
Visit Reason
Inspection identified 16 standard health citations and 8 life safety code citations, mostly Level 2 severity, with deficiencies in ADL care, care plan revisions, immunizations, facility assessment, food sanitation, environment, and life safety features. All deficiencies were corrected by September 1, 2025 or August 27, 2025 for life safety.
Findings
Inspection identified 16 standard health citations and 8 life safety code citations, mostly Level 2 severity, with deficiencies in ADL care, care plan revisions, immunizations, facility assessment, food sanitation, environment, and life safety features. All deficiencies were corrected by September 1, 2025 or August 27, 2025 for life safety.
Deficiencies (24)
ADL care provided for dependent residents
Care plan timing and revision
Covid-19 immunization
Department criminal history review
Facility assessment
Food procurement,store/prepare/serve-sanitary
Free from misappropriation/exploitation
Free of accident hazards/supervision/devices
Free of medication error rts 5 prcnt or more
Infection control
Influenza and pneumococcal immunizations
Label/store drugs and biologicals
Provided diet meets needs of each resident
Safe/clean/comfortable/homelike environment
Self-determination
Treatment/svcs to prevent/heal pressure ulcer
Building construction type and height
Corridor - doors
Discharge from exits
Electrical equipment - power cords and extens
Hazardous areas - enclosure
Hvac
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Capacity: 98
Deficiencies: 13
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.
Deficiencies (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
Facility licensed capacity: 98
Resident census: 92
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
Annual Inspection
Deficiencies: 2
Date: Aug 25, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for pressure ulcer care and environmental safety.
Findings
The facility failed to provide appropriate pressure ulcer care for one resident by not initiating treatment for a Stage 2 pressure ulcer for five days. Additionally, the facility did not maintain a safe, clean, and comfortable environment, as evidenced by soiled and damaged care equipment for two residents.
Deficiencies (2)
F 0686: The facility did not ensure care was provided to promote healing and prevent new pressure ulcers for Resident #249, who had a Stage 2 pressure ulcer on admission with no treatment for five days.
F 0921: The facility failed to maintain a safe, functional, sanitary, and comfortable environment; Resident #42's wheelchair was heavily soiled and damaged, and Resident #69's tube feeding equipment was heavily soiled.
Report Facts
Residents reviewed for pressure ulcers: 4
Residents reviewed for environment: 8
Wound measurements: 1
Wound measurements: 3
Wound measurements: 1.2
Wound measurements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant #5 | Documented wound care notes for Resident #249. | |
| Director of Nursing (DON) | Interviewed regarding pressure ulcer care policies and practices. | |
| Nurse Practitioner (NP) | Interviewed about normal practice for new admissions and skin issue notifications. | |
| Registered Nurse Unit Manager (RNUM) #1 | Interviewed about admission assessments and care plan initiation for pressure ulcers. | |
| Director of Maintenance/Housekeeping (DMH) | Interviewed regarding cleaning responsibilities and observations of soiled equipment. | |
| Administrator | Interviewed about expectations for cleaning and equipment replacement. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Aug 25, 2023
Visit Reason
Inspection found 10 standard health citations, all Level 2 severity, involving assistive devices, care plan revisions, equipment safety, food sanitation, Medicaid/Medicare notices, transfer notices, accommodations, environment, and pressure ulcer treatment. All deficiencies were corrected by October 18, 2023.
Findings
Inspection found 10 standard health citations, all Level 2 severity, involving assistive devices, care plan revisions, equipment safety, food sanitation, Medicaid/Medicare notices, transfer notices, accommodations, environment, and pressure ulcer treatment. All deficiencies were corrected by October 18, 2023.
Deficiencies (10)
Assistive devices - eating equipment/utensils
Care plan timing and revision
Essential equipment, safe operating condition
Food procurement,store/prepare/serve-sanitary
Medicaid/medicare coverage/liability notice
Notice of bed hold policy before/upon trnsfr
Notice requirements before transfer/discharge
Reasonable accommodations needs/preferences
Safe/functional/sanitary/comfortable environ
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Annual Inspection
Deficiencies: 9
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Oct 13, 2022
Visit Reason
Inspection identified 16 life safety code citations, all Level 2 severity, related to cooking facilities, electrical equipment and systems, fire drills, building systems, hazardous areas, doors, walls, administration, physical environment, smoke detection, and sprinkler systems. All deficiencies were corrected by December 9, 2022.
Findings
Inspection identified 16 life safety code citations, all Level 2 severity, related to cooking facilities, electrical equipment and systems, fire drills, building systems, hazardous areas, doors, walls, administration, physical environment, smoke detection, and sprinkler systems. All deficiencies were corrected by December 9, 2022.
Deficiencies (16)
Cooking facilities
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Fire drills
Fundamentals - building system categories
Hazardous areas - enclosure
Horizontal sliding doors
Interior wall and ceiling finish
Maintenance, inspection & testing - doors
Organization and administration
Physical environment
Smoke detection
Sprinkler system - installation
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Upholstered furniture and mattresses
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 17, 2022
Visit Reason
Inspection found 1 standard health citation, Level 2 severity, related to reporting to the national health safety network. Deficiency was widespread and not corrected at time of report.
Findings
Inspection found 1 standard health citation, Level 2 severity, related to reporting to the national health safety network. Deficiency was widespread and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 12
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.
Deficiencies (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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