14 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Middletown, NY
1-star overall rating with 1-star inspections with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
120 Highland Avenue, Middletown, NY
(845) 342-1033
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
98
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1976-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.56
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
11,073
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.92
Baseline 23.04% · Performance 22.19% · Measure score 0.92 · Achievement 0 · Improvement 0.92
Healthcare-associated infections
1.40
Baseline 7.94% · Performance 7.41% · Measure score 1.40 · Achievement 1.40 · Improvement 1.28
Total nurse turnover
4.07
Baseline 55.32% · Performance 47.06% · Measure score 4.07 · Achievement 4.07 · Improvement 2.21
Adjusted total nurse staffing
0.87
Baseline 2.66 hours · Performance 3.08 hours · Measure score 0.87 · Achievement 0 · Improvement 0.87
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 8.88% · Lower 95% interval 7.58% |
| Discharge to community | 40.53% |
50.57%
10 pts worse
|
Worse than the National Rate · Eligible stays 146 · Observed rate 32.88% · Lower 95% interval 32.5% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 81 · Denominator 81 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 81 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 18 · Denominator 33 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 15 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 6.17% |
2.29%
3.9 pts worse
|
Numerator 5 · Denominator 81 · Adjusted rate 4.56% |
| Healthcare-associated infections requiring hospitalization | 7.41% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 8.25% · Lower 95% interval 4.7% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 129 · Denominator 129 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 17 · Denominator 33 |
| Transfer of health information to provider | 70.73% |
95.95%
25.2 pts worse
|
Numerator 29 · Denominator 41 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.32% |
25.2%
17.9 pts worse
|
Numerator 3 · Denominator 41 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.7% |
91.2%
12.5 pts worse
|
93.4%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.4% · Q2 82.3% · Q3 76.9% · Q4 82.7% · 4Q avg 78.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
95.3%
1.3 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.0%
0.5 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.5% · Q3 2.6% · Q4 3.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
18.5%
16.1 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 14.6% |
6.1%
8.5 pts worse
|
5.4%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 22.7% · Q3 8.1% · Q4 9.2% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
13.5%
2.5 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 11.7% · Q3 11.7% · Q4 10.0% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
14.8%
6.2 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.4% · Q3 15.0% · Q4 8.6% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.0% |
15.1%
6.9 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 25.6% · Q3 30.0% · Q4 15.4% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
15.5%
0.5 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 18.7% · Q3 22.7% · Q4 10.5% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.4%
0.3 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 2.7% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.1% |
20.8%
10.7 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 10.4% · Q3 12.3% · Q4 1.2% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
6.9%
2 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.7% · Q3 5.6% · Q4 2.9% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.9% |
76.7%
50.8 pts worse
|
81.7%
55.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 17.3% · Q3 25.0% · Q4 52.9% · 4Q avg 25.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
9.7%
7.2 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 17.3% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.2%
1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 4.9% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.9% |
78.8%
49.9 pts worse
|
79.7%
50.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 28.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
20.6%
8.5 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 30.6% · Expected 25.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-27
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-27
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-27
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-27
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-08-27
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-27
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-27
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-04-06
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-04-06
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2018-06-28
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-06-28
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-06-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-06-28
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-06-28
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-06-28
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-06-28
Inspection history
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-09-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-01
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-09-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-01
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-09-01
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-09-01
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-09-01
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-09-01
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-01
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-01
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-18
Health
Keep all essential equipment working safely.
Corrected 2023-10-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-18
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-18
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-18
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-18
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-18
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-10-18
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-03-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-20
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-03-20
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2020-03-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-20
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-03-20
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-03-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-20
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-03-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-03-20
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-20
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-03-20
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Nearby options
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