HIGHLAND REHABILITATION AND NURSING CENTER

Nursing Home Inspector

120 HIGHLAND AVENUE
MIDDLETOWN, NY 10940
Orange County
Phone: 845-342-1033
Provider Number: 335526
Last Inspection: 01/27/2017

About the Nursing Home

Number of Beds: 98
Number of Residents: 90
Beds Available: 8
Percent Occupancy: 92%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

0

Facility
8

County
14

NY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

0

2017
12

2016
3

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/15/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 5/6/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/6/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/6/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 5/6/2016
 

3/17/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep all essential equipment working safely. Isolated : Minimal 3 5/5/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

9/13/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 11/16/2016
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Widespread : Minimal 5 11/16/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 11/16/2016
 

7/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain comfortable and safe temperature levels. Widespread : Minimal 5 11/16/2016
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 11/16/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NY State Avg
Number of Residents 90 133.10 167.28
Registered Nurses 0.70 0.70 0.74
Licensed Practical / Vocational Nurses 1.22 0.89 0.84
Certified Nursing Assistants 2.67 2.17 2.30
Total Staff Hours 4.60 3.76 3.88

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NY State Avg%
of high risk long-stay residents with pressure ulcers 7 5 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 98 97 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 96 96
of long-stay residents experiencing one or more falls with major injury 2 3 2
of long-stay residents who have depressive symptoms 3 2 8
of long-stay residents who lose too much weight 9 6 6
of long-stay residents who received an antianxiety or hypnotic medication 14 14 15
of long-stay residents who received an antipsychotic medication 21 12 13
of long-stay residents who self-report moderate to severe pain 3 3 3
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 5 24 16
of long-stay residents whose need for help with daily activities has increased 10 13 13
of long-stay residents with a catheter inserted and left in their bladder 3 2 1
of long-stay residents with a urinary tract infection 2 4 3
of low risk long-stay residents who lose control of their bowels or bladder 59 58 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 75 89 81
of short-stay residents who had an outpatient emergency department visit 12 12 9
of short-stay residents who made improvements in function 73 71 68
of short-stay residents who newly received an antipsychotic medication 4 1 1
of short-stay residents who self-report moderate to severe pain 16 10 9
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 82 88 82
of short-stay residents who were rehospitalized after a nursing home admission 28 22 21
of short-stay residents who were successfully discharged to the community 48 51 48
of short-stay residents with pressure ulcers that are new or worsened 1 0 0