Cycle 1
Health 2024-03-04 · Fire 2024-03-04
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Middletown, NY
Middletown Park Rehab & Health Care Center
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
121 Dunning Road, Middletown, NY
(845) 343-0801
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
230
Certified beds
Average residents
220
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Epic Healthcare Management
Operator or chain grouping
Approved since
1982-06-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 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
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.49
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
0.55
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
2.92
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,935
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.68
Baseline 18.88% · Performance 17.87% · Measure score 7.68 · Achievement 7.68 · Improvement 4.94
Healthcare-associated infections
0
Baseline 9.21% · Performance 10.67% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.66
Baseline 42.86% · Performance 48.73% · Measure score 3.66 · Achievement 3.66 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.95 hours · Performance 2.64 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.57% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 442 · Observed rate 8.82% · Lower 95% interval 7.14% |
| Discharge to community | 50.8% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 595 · Observed rate 44.03% · Lower 95% interval 46.21% |
| Medicare spending per beneficiary | 1.48 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 99.78% |
95.27%
4.5 pts better
|
Numerator 444 · Denominator 445 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 445 |
| Discharge self-care score | 48.64% |
53.69%
5 pts worse
|
Numerator 125 · Denominator 257 |
| Discharge mobility score | 52.53% |
50.94%
1.6 pts better
|
Numerator 135 · Denominator 257 |
| Pressure ulcers or injuries, new or worsened | 2.47% |
2.29%
0.2 pts worse
|
Numerator 11 · Denominator 445 · Adjusted rate 2.22% |
| Healthcare-associated infections requiring hospitalization | 10.67% |
7.12%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 437 · Observed rate 11.21% · Lower 95% interval 8.09% |
| Staff COVID-19 vaccination coverage | 6.81% |
8.2%
1.4 pts worse
|
Numerator 22 · Denominator 323 |
| Staff flu vaccination coverage | 53.29% |
42%
11.3 pts better
|
Numerator 275 · Denominator 516 |
| Discharge function score | 45.53% |
56.45%
10.9 pts worse
|
Numerator 117 · Denominator 257 |
| Transfer of health information to provider | 97.73% |
95.95%
1.8 pts better
|
Numerator 129 · Denominator 132 |
| Transfer of health information to patient | 94.09% |
96.28%
2.2 pts worse
|
Numerator 191 · Denominator 203 |
| Resident COVID-19 vaccinations up to date | 41.41% |
25.2%
16.2 pts better
|
Numerator 94 · Denominator 227 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
91.2%
6.6 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 97.3% · Q3 97.4% · Q4 98.3% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.3%
2.7 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.0%
0.3 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.1% · Q3 3.7% · Q4 5.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.0% |
18.5%
4.5 pts better
|
11.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 16.1% · Q3 10.4% · Q4 16.0% · 4Q avg 14.0% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.1%
About the same
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 6.5% · Q3 4.7% · Q4 3.5% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
13.5%
0.5 pts worse
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 14.6% · Q3 14.0% · Q4 14.2% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
14.8%
9.4 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.7% · Q3 5.2% · Q4 6.1% · 4Q avg 5.4% · 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 | 16.7% |
15.1%
1.6 pts worse
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 21.3% · Q3 13.1% · Q4 3.3% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
15.5%
4.2 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 13.0% · Q3 6.3% · Q4 7.3% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.5% · Q3 0.4% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.4%
0.4 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.1% · Q3 0.5% · Q4 0.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
20.8%
0.3 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 21.7% · Q3 21.9% · Q4 12.9% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
6.9%
3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.2% · Q3 5.2% · Q4 3.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
76.7%
17.9 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 94.9% · Q3 96.0% · Q4 96.5% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
9.7%
3.5 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 5.5% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
78.8%
16.7 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
20.6%
0.2 pts worse
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 20.4% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-25 · Fire 2021-05-25
2 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2020-01-17 · Fire 2020-01-17
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
K321 · Smoke Deficiencies
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 2024-03-20
D · Potential for more than minimal harm
2024-03-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-03-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-07
E · Potential for more than minimal harm
2021-05-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-07-21
E · Potential for more than minimal harm
2021-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-21
E · Potential for more than minimal harm
2021-05-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-07-21
E · Potential for more than minimal harm
2021-05-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-05-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-05-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-07-21
E · Potential for more than minimal harm
2020-01-17
K321 · Smoke Deficiencies
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 2020-04-01
E · Potential for more than minimal harm
2020-01-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-01
D · Potential for more than minimal harm
2020-01-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-04-01
D · Potential for more than minimal harm
2020-01-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-04-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2025-04-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
E · Potential for more than minimal harm
2024-03-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F584 · Resident Rights Deficiencies
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 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F688 · Quality of Life and Care Deficiencies
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 2024-04-15
D · Potential for more than minimal harm
2024-03-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-15
E · Potential for more than minimal harm
2021-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-20
D · Potential for more than minimal harm
2020-01-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-12
D · Potential for more than minimal harm
2020-01-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-12
Penalties and ownership
What sits behind the stars
Ownership
Jozefovic, Herbert
5% Or Greater Direct Ownership Interest · Individual
Neuman, Mark
5% Or Greater Direct Ownership Interest · Individual
Brach, Samuel
5% Or Greater Direct Ownership Interest · Individual
Fagenson, Robert
5% Or Greater Direct Ownership Interest · Individual
Neuman, Gerald
5% Or Greater Direct Ownership Interest · Individual
Feminella, Danielle
Operational/Managerial Control · Individual
Jozefovic, Herbert
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Highland Rehabilitation And Nursing Center
Middletown, NY
1-star overall rating with 1-star inspections with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Campbell Hall Rehabilitation Center Inc
Campbell Hall, NY
1-star overall rating with 1-star inspections with Special Focus status with $245,508 in total fines with 40 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Sapphire Nursing And Rehab At Goshen
Goshen, NY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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