Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Middletown Park Rehab & Health Care Center

Middletown, NY · 230 certified beds · Last Life Safety survey March 4, 2024

CMS Certification Number 335655 · first certified June 1982

Ownership

Operated by EPIC HEALTHCARE MANAGEMENT · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

16
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
6
Inspection & testing records
Of the citations on file

Position within NY

16 citations — more than 61% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (August 2025 to April 2026), and past the point by which nine in ten NY facilities have been surveyed. This facility’s last Life Safety survey was March 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 16 Life Safety citations above. The Physical Environment Index

  • F-0584 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.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.

This facility16NY median13National median11
Citations on file over three years, compared
MeasureCitations
This facility16
Median facility in NY13
Median facility nationally11

Survey history

Citations at each Life Safety survey
42020-0162021-0562024-03
Citations at each Life Safety survey
Survey dateCitations
January 17, 20204
May 25, 20216
March 4, 20246

Most-cited tags

Most-cited tags at this facility
K-03212K-09211K-02911K-03531K-09181K-01611K-09141K-03721
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22024-03-04
K-0921Ensure that testing and maintenance of electrical equipment is performed.12020-01-17
K-0291Install emergency lighting that can last at least 1 1/2 hours.12021-05-25
K-0353Inspect, test, and maintain automatic sprinkler systems.12021-05-25
K-0918Have generator or other power source capable of supplying service within 10 seconds.12020-01-17
K-0161Use approved construction type or materials.12024-03-04
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12021-05-25
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12024-03-04

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 5
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Egress Deficiencies 4
  • Services Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies5
Gas, Vacuum, and Electrical Systems Deficiencies4
Egress Deficiencies4
Services Deficiencies1
Construction Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 4, 2024 — 6 citations

Citations issued on March 4, 2024
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Fire Safety Evaluation Survey (April 15, 2024)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (April 15, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (March 20, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (March 20, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (April 15, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (March 7, 2024)

May 25, 2021 — 6 citations

Citations issued on May 25, 2021
TagWhat the surveyor checksStatus
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (July 21, 2021)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (July 21, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (July 21, 2021)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (July 21, 2021)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (July 21, 2021)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (July 21, 2021)

January 17, 2020 — 4 citations

Citations issued on January 17, 2020
TagWhat the surveyor checksStatus
K-0281Install proper backup exit lighting.Deficient, Provider has date of correction (April 1, 2020)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (April 1, 2020)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 1, 2020)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (April 1, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.