Middletown Park Rehab & Health Care Center

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (2644658) the facility did not ensure each resident received treatment in accordance with professional standards of practice for one (1) of three (3) residents (Resident #1) reviewed for COVID-19 infection. Specifically, an Atrovent inhaler (bronchodilator breathing medication) was not administered to Resident #1 on 10/18/2025 and 10/19/2025 as per physician order.

Inspectors wroteBased on record review, and interviews conducted during the Abbreviated Survey (NY00371502), the facility did not ensure residents received quality of care in accordance with professional standards of practice for 1 of 3 residents reviewed. for Specifically, Resident #1 had an admission weight of 89.4lbs on 1/13/25. On 1/14/25 the resident's weight was recorded in the electronic medical record by Licensed Practical Nurse #2 as 113 pounds. Licensed Practical Nurse #2 did not notify the Physician of the significant weight gain nor request a reweigh. 2) On 1/27/2025 the Registered Dietician informed the Medical director that Resident #1's weight was 94lbs and this prompted the medical director to initiate a weight gain plan for the resident which the resident refused. 3) There was no consistent indication of how/when the weights were obtained as ordered. [...]

Inspectors wroteBased on record review, and interviews conducted during the Abbreviated Survey (NY00371502), the facility did not ensure that a residents' medical record contained an accurate representation and included information that accurately reflected the resident's condition, and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team for 1(Resident #1) of 3 residents reviewed. Specifically Resident #1 who was admitted on [DATE] was weighed during the evening shift and was 89.4 pounds and then weighed on 1/14/25 and was 113 pounds with inaccurate subsequent weights between 1/14-1/29/25. [...]

Inspectors wroteBased on observation, interview, and record review, conducted during the recertification survey, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1. Expired foods were stored in the dairy cooler, 2. Staff did not appropriately use gloves and wash their hands before touching clean dishes, 3. Staff did not wear a hairnet that contained all of their hair in order to prevent hair from contacting food, 4. Storage racks used to store cleaned and sanitized food preparation equipment were not being maintained in a sanitary condition, 5. Two walk-in refrigerated units and one walk in freezer unit were not maintained in a sanitary condition to ensure for food safety, and 6. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey from 2/26/24-3/04/24, the facility did not ensure residents had the right to a dignified experience for 3 of 18 residents (Residents #5, #30, and #36) reviewed for dining. Specifically, two licensed practical nurses were observed standing over Residents #5, #30, and #36 while assisting the residents with their meals.

Inspectors wroteBased on observation, interview, and record review during the recertification survey from 2/26/24-3/04/24, the facility did not ensure 1 of 2 residents (Resident #175) reviewed for restraints, was free from physical restraints. Specifically, there was no documented evidence Resident #175 was assessed, consented to, had a medical justification, a physician order, or a plan of care for the use of straps on their Broda chair.

Inspectors wroteBased on observation, interview and record review conducted during the Recertification Survey from 2/26/24-3/04/2024, it was determined for 1 of 2 residents (Resident #175) reviewed for restraints, that the facility did not ensure a comprehensive care plan that included measurable goals and interventions for the use of restraints. Specifically, Resident #175 did not have a care plan in place for the use of a Broda chair with thigh straps.

Inspectors wroteBased on observations, record review and interviews conducted during a recertification survey from 2/26/24-3/04/24, the facility did not ensure for 1 of 3 residents (Resident #45) reviewed for activities of a daily living, received the necessary services to maintain personal hygiene. Specifically, Resident #45 did not receive their shower on multiple occasions.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 2/26/24 to 03/04/24, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and/or the comprehensive person-centered care plan for 1 of 4 residents (Resident # 43) reviewed for skin conditions. Specifically, for Resident #43 with a left toe arterial wound and a shearing wound of the sacrum, the use of a pressure relieving mattress and offloading of the heels were not implemented as per wound physician recommendation and the comprehensive care plan.

Inspectors wroteBased on observations, record review and interviews conducted during a recertification survey from 2/26/24-3/04/24, the facility did not ensure for 1 of 1 resident (Resident #45) reviewed for positioning and limited mobility, that appropriate treatment and services were provided to improve and/or prevent a further decrease in range of motion (ROM). Specifically, Resident #45 was observed on multiple occasions not wearing a hand roll to the left hand as ordered.

Inspectors wrote2. Resident #38 had diagnoses including obstructive and reflux uropathy, retention of urine, and chronic kidney disease stage 3. Physician orders documented: - on 11/3/2023, ensure catheter securement device was in place and privacy bag over drainage bag when out of bed. - on 11/9/2023, indwelling urethral catheter for urinary retention secondary to neurogenic bladder, and urinary retention secondary to obstructive uropathy. - on 11/23/2023, foley care every shift. - on 2/19/2024, floor mats bilateral sides of the bed while resident is in bed each shift. During an observation on 2/27/2024 at 11:37 AM, Resident #38 was in bed, and the indwelling catheter bag was uncovered on the bedside floor mat and was touching the bed. During an observation on 2/28/2024 at about 2:40PM, Resident #38 was in bed, and the indwelling catheter bag and tubing were uncovered on the bedside floor mat. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00331764) from 2/26/24 to 3/04/24, it was determined for 2 of 6 resident care units (Units 2 and 6) the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, wheelchairs and/or geri-chairs were soiled and/or ripped for Residents #53, #106, and #63 on Unit 6 and Residents #148, and #116 on unit 2. This was evidenced by the following: An undated Policy and Procedure titled Wheelchair/Geri-Chair Cleaning documented the purpose was to ensure a clean environment for residents, thus maintaining infection control. There was no documented evidence in the untitled wheelchair cleaning schedule to indicate that wheelchairs on Unit 6 had been cleaned since 2/8/24, or that they were all cleaned. [...]

Inspectors wroteBased on observations, interviews and record reviews during a Recertification Survey the facility did not ensure that the Infection Prevention and Control Program (IPCP) was implemented to prevent the development and transmission of communicable diseases and infection for 3 of 3 residents (Resident # 109, Resident #190, and Resident #112) reviewed for Infection Control. Specifically, the facility did not investigate the root cause of a Scabies outbreak and did not report the outbreak to the New York State Department of Health (NYSDOH).

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that a care plan intervention to address a significant weight loss was implemented. This was evident for one of three residents reviewed for nutrition.(Resident #106).

Inspectors wroteBased on observation, interview and record review conducted during the recent recertification survey, the facility did not ensure that its medication error rate was within an acceptable range (0-5%). During medication administration 2 errors were observed out of 27 opportunities for error resulting in a medication error rate of 7.41%. This was evident for 2 of 12 residents (#413 and #166) observed during medication administration.