Inspection Reports for
Middletown Park Rehabilitation & Health Care Center
121 Dunning Road, Middletown, NY, 10940
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The abbreviated survey was conducted to evaluate compliance with professional standards of practice related to medication administration, specifically regarding treatment for COVID-19 infection.
Findings
The facility failed to ensure that Resident #1 received the prescribed Atrovent HFA inhaler as ordered on multiple occasions, resulting in minimal harm or potential for actual harm. The facility subsequently obtained a substitute medication order after notifying the physician and resident's family.
Deficiencies (1)
F 0684: The facility did not administer the Atrovent HFA inhaler to Resident #1 on 10/18/2025 and 10/19/2025 as ordered, and failed to notify the physician promptly. A substitute medication was later ordered after the delay was identified.
Report Facts
Residents reviewed for COVID-19 infection: 3
Missed medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Reported missing medication and re-ordered Atrovent HFA inhaler | |
| Registered Nurse #3 | Reported missing Atrovent inhaler after 5 PM dose on 10/18/2025 | |
| Medical Doctor #1 | Medical Doctor | Expected notification of missed medication and ordered substitute medication |
| Registered Nurse Unit Manager #2 | Stated nursing staff should have notified supervisor about missing medication | |
| Registered Nurse Supervisor #4 | Contacted pharmacy and physician to obtain substitute medication and informed resident's family |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care and medical record accuracy, focusing on weight monitoring and nutritional assessment for Resident #1.
Findings
The facility failed to ensure accurate weight monitoring and documentation for Resident #1, resulting in inconsistent and inaccurate weights recorded in the electronic medical record and weight sheets. The Registered Dietician and nursing staff did not consistently follow up on significant weight changes, leading to inadequate nutritional assessment and communication with the medical team.
Deficiencies (2)
F 0684: The facility did not ensure residents received quality care according to professional standards, as Resident #1 had inconsistent and inaccurate weight recordings, and staff failed to notify the physician or request reweighs as ordered.
F 0842: The facility failed to maintain accurate medical records for Resident #1, with inaccurate weight documentation causing inadequate nutritional assessment and poor communication among the care team.
Report Facts
Weights recorded: 89.4
Weights recorded: 113
Weights recorded: 91.8
Weights recorded: 94
Weights recorded: 112.8
Weights recorded: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Did not notify physician of significant weight gain or request reweigh; input inaccurate weight into EMR |
| Registered Dietician | Registered Dietician | Did not follow up on inconsistent weights, failed to document reweighs, and inaccurately reported weights to medical team and family |
| Medical Director | Medical Director | Was not notified of significant weight loss; expected documentation and reweighs for significant weight changes |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Responsible for reviewing weights and consulting with Dietician; acknowledged failure to check weight books consistently |
| Director of Nursing | Director of Nursing | Oversaw documentation of weights by Certified Nurse Aides and review by unit managers; stated expectations for weight monitoring |
| Certified Nurse Aide #1 | Certified Nurse Aide | Responsible for obtaining weights and documenting dates and initials on weight sheets; admitted to missing dates and documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
Complaint survey with 2 standard health citations related to quality of care and resident records.
Findings
Complaint survey with 2 standard health citations related to quality of care and resident records.
Deficiencies (2)
Quality of care
Resident records - identifiable information
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Mar 4, 2024
Visit Reason
The inspection was conducted as part of recertification and abbreviated surveys to assess compliance with housekeeping and maintenance standards in resident care units.
Findings
The facility failed to provide adequate housekeeping and maintenance services to maintain a safe, clean, and homelike environment. Several wheelchairs and geri-chairs were found soiled, ripped, or broken across two resident care units, and staff were unaware or did not ensure timely cleaning or repair.
Deficiencies (2)
F 0584: The facility did not maintain a safe, clean, and homelike environment as wheelchairs and geri-chairs were soiled and ripped in Units 2 and 6. Cleaning schedules were not documented or followed, and staff were unaware of the condition of the chairs.
During an interview on 02/29/24, the Administrator stated that ripped chairs should be fixed or replaced and it was unacceptable for residents to be in soiled, ripped, or broken chairs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Housekeeping Supervisor | Interviewed regarding wheelchair cleaning schedule and unawareness of soiled or ripped chairs. |
| Staff #1 | Certified Nurse Aide | Interviewed about notifying Nurse Manager of soiled or ripped wheelchairs. |
| Staff #2 | Nurse Manager | Interviewed about staff reporting soiled or ripped wheelchairs and calling housekeeping. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Mar 4, 2024
Visit Reason
The inspection was a recertification survey conducted from 2024-02-26 to 2024-03-04 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, improper use of physical restraints without proper documentation or care plans, failure to provide scheduled showers, inadequate wound care and pressure injury prevention, failure to maintain range of motion devices, unsafe food handling and storage practices, and lapses in infection prevention and control practices.
Deficiencies (8)
F 0550: The facility did not ensure residents had the right to a dignified experience during meals as staff were observed standing over residents while assisting with eating.
F 0604: The facility used physical restraints (thigh straps on Broda chair) on Resident #175 without documented assessment, consent, physician order, or care plan.
F 0656: The facility failed to develop and implement a comprehensive care plan with measurable goals and interventions for the use of restraints for Resident #175.
F 0677: Resident #45 did not receive scheduled showers on multiple occasions due to broken shower equipment and lack of communication.
F 0684: Resident #43 with skin wounds did not receive pressure relieving mattress or heel offloading as recommended by wound care physician and care plan.
F 0688: Resident #45 was observed not wearing a prescribed left hand roll to maintain range of motion, despite orders and nursing instructions.
F 0812: The facility failed to ensure proper food safety practices including storage of expired milk, inadequate hand hygiene by staff, improper hairnet use, unsanitary storage racks, unclean walk-in refrigerators and freezer, and unsafe cold food holding temperatures.
F 0880: Infection prevention and control practices were deficient as foley catheter tubing and bags were observed resting on the floor without barriers for multiple residents, and oxygen tubing was found on the floor without proper storage, increasing risk of infection.
Report Facts
Expired milk cartons: 120
Closing checklist completion days: 10
Cold food temperatures: 44.6
Cold food temperatures: 51.2
Cold food temperatures: 51.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #8 | Licensed Practical Nurse | Observed standing over residents while assisting with meals and interviewed about proper meal assistance. |
| Staff #9 | Licensed Practical Nurse | Observed standing over residents while assisting with meals and interviewed about proper meal assistance. |
| Staff #5 | Rehabilitation Director | Interviewed regarding use of restraints and care plans for Resident #175. |
| Staff #7 | Licensed Practical Nurse Unit Manager | Interviewed regarding Resident #45 shower schedule and hand roll use. |
| Staff #10 | Certified Nurse Aide | Interviewed regarding use of restraints and shower equipment. |
| Staff #24 | Food Service Director | Interviewed regarding expired milk storage, food safety practices, and kitchen cleaning. |
| Staff #26 | Cook/Supervisor | Interviewed regarding kitchen equipment maintenance and cleaning checklists. |
| Staff #12 | Registered Nurse | Interviewed regarding oxygen equipment infection control. |
| Staff #13 | Registered Nurse | Interviewed regarding oxygen equipment infection control. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Mar 4, 2024
Visit Reason
Complaint survey with 9 standard health citations and 7 life safety code citations, all Level 2 severity, mostly corrected by April 15, 2024.
Findings
Complaint survey with 9 standard health citations and 7 life safety code citations, all Level 2 severity, mostly corrected by April 15, 2024.
Deficiencies (15)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Increase/prevent decrease in rom/mobility
Infection prevention & control
Quality of care
Resident rights/exercise of rights
Right to be free from physical restraints
Safe/clean/comfortable/homelike environment
Building construction type and height
Exit signage
Hazardous areas - enclosure
Maintenance, inspection & testing - doors
Physical environment
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 25, 2021
Visit Reason
The inspection was conducted as a Recertification Survey to assess the facility's compliance with infection prevention and control requirements.
Findings
The facility failed to implement an effective Infection Prevention and Control Program to prevent the development and transmission of communicable diseases, specifically failing to investigate and report a Scabies outbreak involving three residents to the New York State Department of Health.
Deficiencies (1)
F 0880: The facility did not investigate the root cause of a Scabies outbreak and failed to report the outbreak to the New York State Department of Health despite having three confirmed cases among residents.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the Scabies outbreak investigation and reporting | |
| Facility Administrator | Interviewed regarding awareness and reporting of Scabies cases |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 17, 2020
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to implement a care plan intervention addressing significant weight loss for one resident and had a medication error rate exceeding the acceptable threshold, with two medication errors observed during administration.
Deficiencies (2)
F 0656: The facility did not implement a care plan intervention to address significant weight loss for Resident #106, despite documented weight loss exceeding 11% over two months.
F 0759: The facility's medication error rate was 7.41%, exceeding the acceptable limit of 5%, with errors observed in medication administration for Residents #413 and #166.
Report Facts
Weight loss percentage: 11.2
Medication error rate: 7.41
Medication errors observed: 2
Residents observed for medication administration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian | Interviewed regarding weight loss and care plan for Resident #106 | |
| RN#1 | Nurse involved in medication errors for Residents #413 and #166 |
Inspection Report
Capacity: 60
Deficiencies: 0
Visit Reason
There were 2 inspections with citations and 4 inspections with no citations during the reporting period.
Findings
There were 2 inspections with citations and 4 inspections with no citations during the reporting period.
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