Houghton Rehabilitation & Nursing Center

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure that there was sufficient nursing staff with the appropriate competencies on a 24-hour basis to provide care to all residents for one of one facility reviewed for sufficient staffing. Specifically, the facility did not meet their minimum staffing levels for Certified Nurse Aides to meet the needs of each resident as they utilized non-certified Resident Assistants to meet their established minimums.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure there were services of a Registered Nurse for at least eight (8) consecutive hours, seven (7) days a week unless when waived. Specifically, the facility did not have eight (8) consecutive hours of Registered Nurse coverage on 3/30/25, 4/5/25, 4/12/25 and 4/13/25 as required and did not have a waiver. The finding is: The policy and procedure titled Registered Nurse Coverage & Full-Time Director of Nursing revised April 2025 documented, the facility ensures compliance with federal regulations by ensuring a registered nurse is onsite for a minimum of eight (8) consecutive hours each day, seven (7) days per week. Scheduling of Registered Nurse coverage will be handled by the Staffing Coordinator or designee to ensure compliance. [...]

Inspectors wroteBased on record review and interview conducted during a Standard survey completed 5/2/25, the facility did not ensure any individual working in the facility as a nurse aide for more than 4 months was competent to provide nursing and nursing related services and that individual has completed a training and competency evaluation program or a competency evaluation program approved by the State for six (6) (Resident Assistant #1, #3, #4, #5, #6, and #7) of seven (7) resident assistants reviewed. Specifically, Resident Assistants #1, #3, #4, #5, #6 and #7 worked greater than 4 months (120 days) as a nurse aide without receiving nurse aide certification. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 5/2/2025, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for two (2) (Resident #18 and #52) of two (2) residents reviewed for choices. Specifically, Resident #18 was not provided with the frequency of showers they preferred and Resident #52 was not offered or provided with a shower as scheduled.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 5/2/25, the facility did not provide services consistent with professional standards of quality for one (1) (Resident #6) of one (1) resident reviewed for dialysis. Specifically, Resident #6 did not receive Torsemide 40 milligrams as ordered by the physician on non-dialysis days, and it was given on dialysis days. The finding is: The policy titled Orders dated 3/19 documented, it is the facility's policy that all orders are accurately transcribed and executed in a timely manner per physician/Nurse Practitioner orders. The healthcare provider will provide timely and appropriate medical orders, and the healthcare provider will verify the accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure that residents who had a suprapubic catheter (tube inserted into the bladder, through the abdomen, to drain urine) received the appropriate care and services to manage catheters for one (1) (Resident #20) of three (3) residents reviewed. Specifically, staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) during care, improperly emptied the drainage bag, did not offer Resident #20 a leg drainage bag and did not ensure the catheter drainage bag and tubing remained off the floor. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during a Complaint investigation (#NY00375024) during a Standard survey completed on 5/2/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #28, #42, and #67) of five (5) residents reviewed for infection prevention and control and one (1) (Resident #31) of three (3) residents observed for pressure ulcers. Specifically, Residents #28, #42, and #67 started experiencing cold signs and symptoms (wet cough, raspy voice, sore throat), were tested for influenza A, respiratory syncytial virus, and COVID-19 on 4/29/25, and were not placed on transmission based precautions pending their test results; [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00340465) the facility failed to protect residents from sexual abuse for one (Resident #2) of three residents reviewed for abuse. Specifically, Resident #1 with a history of sexually aggressive behaviors was found engaged in sexual activity with Resident #2. Resident #2 wandered into Resident #1's room without staff's knowledge. Resident #1 and Resident #2 both lacked the ability to consent due to their cognitive impairment and inability to express their feelings. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, it was determined psychosocial harm occurred that is not immediate jeopardy. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated Survey (Complaint #NY00324791) completed on 2/12/24, the facility did not ensure residents had the right to be free from sexual abuse for one (Resident #1) of four residents reviewed. Specifically, Resident #2 was observed by staff engaged in non-consensual sexual contact with Resident #1. The finding is: The policy and procedure titled Abuse- Investigation, Protection, and Reporting dated 10/24/22 documented a policy of zero tolerance will be enforced if any violations of these rights occur. Residents shall not be subjected to abuse and mistreatment by anyone including but not limited to: facility employees, medical staff, other residents. The policy and procedure documented residents should be evaluated to determine whether the resident has the capacity to consent to sexual activity. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 3/31/23, the facility did not ensure that residents had a right to a safe, clean, comfortable, and homelike environment for four (100 Unit, 200 Unit, 300 Unit, 400 unit) of four resident units. Specifically, there was a lack of hot water in resident rooms and care areas. Sink faucets that did not function properly. Floor transitions between the hallway and resident living spaces in poor condition. Poor lighting in resident living spaces and safety floor mats soiled and in poor condition (Resident #29).

Inspectors wroteBased on observation, interview and record review during a Standard survey starting on 3/27/23 and completed on 3/31/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide (CO) detectors shall be maintained in good working order and tested per Section 915 and the manufacturer's instructions/ recommendations. This affected the Basement and two (Main Street and 200 Wing) of five resident use wings and the South Nurse's station (nurses station located at the center point between the building's five wings).

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 3/23/23, the facility did not ensure that the individual financial record was available to the residents through quarterly statements and upon request for two (Residents #14 and #41) of two residents reviewed. Specifically, the facility did not provide quarterly statements of their individual financial record for personal funds.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 3/31/23, the facility did not implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for two residents (Resident #2 and #62) of 2 residents reviewed. Specifically, Residents (#2, #62) had a history of falls, and did not have safety floor mats in place next to their beds as planned.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 3/31/23, the facility did not post, on a daily basis: the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility did not ensure staffing sheets were completed daily and that they were updated at the beginning of each shift to reflect changes in the schedule. The finding is: The policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers dated 4/1/2018 documented the information recorded on the form shall include: The resident census at the beginning of the shift for which the information is posted; The actual time worked during that shift for each category and type of nursing staff; Total number of licensed and non-licensed nursing staff working for the posted shift. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 3/7/23 the facility did not ensure resident rooms were equipped to assure full visual privacy for four (100 Unit, 200 Unit, 300 Unit, 400 Unit) of four resident units. This involved Resident Rooms #114, #221, #304, #306, #411, and #414.

Inspectors wroteBased on observation, interview and record review conducted during a Standard Survey completed on 11/22/19, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for one (Resident #140) of four residents reviewed for abuse. Specifically, there was a lack of an investigation of the resident with scabs on the top of both hands and bruising of the left index finger. The finding is: The undated facility Policy and Procedure (P&P) titled Weekly Skin Assessment revealed weekly skin assessments will be completed on each resident in the Electronic Medical Record (EMR). Best practice is to do skin check on shower day. The licensed nurse will examine the skin of each resident weekly on a specified day. If an abnormality is found, then a weekly wound form is initiated and the physician, Director of Nursing (DON) /designee, and family are notified. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 11/22/19, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #53) of three residents observed for ADL's. Specifically, a resident who was dependent on staff for ADL's, had long, jagged fingernails with brown debris under multiple fingernails and preferred them clean and cut. The finding is: Review of the facility policy and procedure titled Nail Care with a revision date of 2/18 revealed nail care should be provided on bath/shower day and as needed. 1. Resident #53 had diagnoses which included diabetes, Parkinson's (a nervous system disorder that affects movement, often including tremors), and hypertension (high blood pressure). [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 11/22/19, the facility did not ensure the attending physician documented in the resident's medical record an identified irregularity was reviewed and what if any, action had been taken to address it for one (Resident #27) of five residents reviewed for unnecessary medications. Specifically, the physician did not document a rationale for not decreasing a resident's psychotropic medications per the pharmacist's recommendation. The finding is: The facility policy titled Medication Regimen Reviews dated 10/2018 documented the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what actions were taken, if any. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 11/22/19, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for two (Residents #27, 37) of five residents reviewed for unnecessary medications. Specifically, a resident admitted with an antipsychotic medication did not have an order for a psychiatric evaluation, did not have documented psychotic behaviors, and was not reviewed by the interdisciplinary team psychotropic medication committee (Resident #37); and a resident on an antipsychotic medication since April 2017 had no documented psychotic behaviors to support ongoing use and lacked an adequate indication for use (Resident #27).

Inspectors wroteBased on interview and record review conducted during the Standard Survey completed on 11/22/19, the facility did not assess the resident using the quarterly review instrument not less frequently than once every three months for four (Residents #2, 15, 19, 20) of four residents reviewed for quarterly resident assessments. Specifically, the residents did not have quarterly Minimum Data Set (MDS - a resident assessment tool) completed timely as required.