Houghton Rehabilitation & Nursing Center

The policy and procedure titled Supervision of Nurse Aide Trainees Post - Nurse Aide Trainee Program Completion revised 3/2022 documented upon successful completion of a New York State approved Nurse Aide Training Program, a nurse aide trainee may be employed to provide care for residents for a period not to exceed 120 days from the date of hire, while they await certification testing. Employment must be discontinued or job reassignment to non-direct care position must be implemented if the trainee does not pass the certification exam within the allowed period.

An undated document provided by the facility titled Job Title: Licensed Nursing Home Administrator that documented the Licensed Nursing Home Administrator was responsible for the overall leadership, management, and administration of the nursing facility in a manner that ensures effective and efficient use of resources to achieve and maintain the highest practicable physical, mental and psychosocial well-being of each resident in full compliance with federal, state and local regulations. The Administrator must oversee and direct operations including clinical care, human resources, budgeting, compliance, resident services and community engagement to ensure the delivery of high-quality care and services.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/02/2025 Houghton Rehabilitation & Nursing Center 9876 Luckey Drive Houghton, NY 14744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

Review of a letter from the New York State Department of Health provided by the facility dated 12/13/24 to

the Administrator documented a notification that the facility was prohibited from conducting nurse aide training and testing for a period of two (2) years from the date imposed. The letter documented the facility was to provide a list of names of the nurse aide trainees currently enrolled in the nurse aide training program and those who have recently completed the program but have not taken the certification examination to the New York State Department of Health. Additionally, the letter documented that an exemption to the ban to

the nurse aide training program and testing may be requested.

Review of an E-mail sent from the facility's Administrator to the Nurse Aide Training Program at Department of Health dated 2/24/25 at 12:10 PM documented, a list of the nurse aide trainees who were waiting to test or that needed to re-test in response to the notification of the ban for the training program at the facility. The listed employees included Resident Assistants #1, #3, #4, #5, #6, and #7.

During an interview on 5/2/25 at 1:18 PM, the Administrator stated they had received the letter dated 12/13/24. Once they received the letter, they had notified the regional staff of the facility. They stated they needed to send into New York State a list of any nurse aide trainee who was still in the nurse aide training class and needed to test for their certification. They stated the nurse aide trainees who had not received their certification should have not been completing hands on care beyond their 120 days of hire. A combination of human resources and scheduling were responsible for removing the nurse aide trainees who were not certified past 120 days of hire from the schedule. The Administrator stated they were responsible for overseeing human resources and scheduling.

During an interview on 5/2/25 at 1:24 PM, the Regional Administrator stated they were a member of the governing body for the facility. Their expectation of the Administrator of the facility was to maintain compliance with federal, state and local regulations. The nurse aide trainees who were in the nurse aide training class and did not receive their certification within 120 days of hire should not have worked as direct care providers past the 120 days of hire. Human resources were responsible to remove those employees from hands on care and the Administrator was responsible to oversee human resources. 10 NYCRR 415.26 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/02/2025 Houghton Rehabilitation & Nursing Center 9876 Luckey Drive Houghton, NY 14744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47750 Based 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; staff did not ensure hand washing after changing their gloves, after cleansing wounds, prior to the application of treatment and between draining wound sites for Resident #31.

The findings are:

The policy titled Influenza Outbreak dated 9/2022, documented implementation of outbreak control measures can be considered as soon as possible when one or more residents have acute respiratory illness with suspected influenza and the results of influenza molecular tests are not available the same day of specimen collection. Note that older adults and other long-term care residents may manifest atypical signs and symptoms of influenza virus infection (e.g. behavior change) and may not have fever. Infection preventionist/designee is responsible for monitoring and overseeing influenza activity within the facility.

Implement isolation protocols for exhibiting influenza symptoms. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions and should be implemented for residents with suspected or confirmed influenza for seven (7) days

after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Test any resident with symptoms of COVID-19 for both viruses.

The policy titled Respiratory Syncytial Virus (RSV) dated 12/20/23, documented respiratory syncytial virus was a common respiratory virus that affected the lungs and bronchi (smaller passageways that carry air to

the lung). The facility followed current guidelines and recommendation for managing respiratory syncytial virus outbreak in the facility. Common symptoms were nonspecific, like a cold and other respiratory infections e.g. runny nose, coughing, sneezing, nasal congestion, and sometimes fever. The virus is spread through respiratory secretions via close contact with infected individuals or contact with contaminated surfaces. Infection Preventionist must be informed of all suspected cases of respiratory syncytial virus and transmission-based precautions, specifically droplet precautions, must be implemented when respiratory syncytial virus is suspected or confirmed.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/02/2025 Houghton Rehabilitation & Nursing Center 9876 Luckey Drive Houghton, NY 14744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

The policy titled Hand Hygiene dated 3/2021, documented it was the expectation of the facility that all personnel perform hand hygiene appropriately in accordance with current standards of practice. Appropriate hand hygiene must be followed by all staff to prevent the spread of infection under the following conditions but not limited to before and after all patient contact, immediately after removing gloves, and before putting

on and after removing personal protective equipment. Hands must be washed with soap and water when visibly soiled, after contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings, and contaminated equipment. Gloves should be used as an adjunct to, not a substitute for hand washing. 1a. Resident #28 had diagnoses including schizoaffective disorder (mental health disorder), spinal stenosis (narrowing of spaces within spine compressing the spinal cord and nerve roots), and anxiety. The Minimum Data Set (a resident assessment tool) dated 3/26/25 documented Resident #28 was cognitively intact, was understood and understands.

The comprehensive care plan dated 12/26/24 documented Resident #28 required an extensive assist of one (1) person for toileting and personal hygiene.

Review of the 24-Hour Summary dated 4/28/25 documented Resident #28 had a moist cough and was requesting cough syrup from the doctor. Nurse Practitioner #1 documented Resident #28 complained of cold signs and symptoms.

Review of 24-Hour Summary dated 4/29/25 documented Resident #28 had worsening respiratory symptoms,

a congested cough and chills. Lungs were rhonchorous (low pitched, gurgling) throughout. Nurse Practitioner #1 ordered a chest x-ray and to swab for COVID-19, influenza, and respiratory syncytial virus. The Director of Nursing was notified along with the emergency contact. Swabs were obtained and sent out for testing. 1b. Resident #42 had diagnoses including pneumonitis (inflammation of the lungs) due to inhaled food or vomit, chronic obstructive pulmonary disorder (lung disease that causes airflow obstruction and breathing problems), and heart failure. The Minimum Data Set, dated dated dated [DATE REDACTED] documented Resident #42 was cognitively intact, was understood and understands.

The comprehensive care plan dated 12/5/24 documented Resident #42 required an extensive assist of one (1) person for toileting and transferring.

Review of 24-Hour Summary dated 4/26/25 documented Resident #42 had a moist cough and cough syrup was given.

Review of 24-Hour Summary dated 4/27/25 documented Resident #42 was given cough syrup.

Review of 24-Hour Summary dated 4/28/25 documented Resident #42 complained of not feeling well and refused a shower, was given cough syrup, and was incontinent of loose stool.

Review of 24-Hour Summary dated 4/29/25 documented Resident #42 had a congested cough and hoarse voice, was given cough syrup. Physician #1 was updated and ordered Mucinex twice a day, COVID-19 and influenza swabs were collected.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/02/2025 Houghton Rehabilitation & Nursing Center 9876 Luckey Drive Houghton, NY 14744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1c. Resident #67 had diagnoses including schizophrenia (mental health disorder) and dementia. The Minimum Data Set, dated dated dated [DATE REDACTED] documented Resident #67 was cognitively intact, was usually understood and usually understands.

The comprehensive care plan dated 4/13/23 documented Resident #67 required an extensive assist of one (1) person for personal hygiene and was dependent on two (2) staff members for toileting.

Review of 24-Hour Summary dated 4/30/25 documented Resident #467 was swabbed for COVID-19, respiratory syncytial virus, and influenza.

During intermittent observations on 4/30/25 at 8:25 AM and 10:12 AM, Residents #28, #42, and #76 did not have isolation precautions in place. There were no posted precautions signs or personal protective equipment outside of their rooms.

During an observation and interview at 11:14 AM, Resident #42 was sitting in their room coughing, it was a wet cough that could be heard from the hallway. Certified Nurse Aide #1 stated Resident #42 had a cough for a couple days, had recently been tested and was not on isolation precautions. Certified Nurse Aide #1 stated Resident #28 had been coughing for a while, had a chest x-ray done the day prior and was not on isolation precautions. Certified Nurse Aide #1 stated Resident #67 had a cough here and there, was unsure if

they were recently tested , and was not on isolation precautions.

During an interview on 4/30/25 at 11:50 AM, Licensed Practical Nurse #1 stated Residents #28 and #42 had wet coughs and were tested for influenza, respiratory syncytial virus and COVID-19 on 4/29/25 and were not

on isolation precautions. They stated Resident #67 had a cough and was tested on the morning of 4/30/25.

They stated the policy was for any resident experiencing respiratory symptoms to be placed on droplet isolation precautions until swab results were obtained, requiring staff to wear a gown, gloves, and mask when providing care. Licensed Practical Nurse #1 stated they did not know why they were not on isolation precautions; they would have to consult with the Infection Preventionist. They stated it was important for staff to follow the proper isolation precautions to prevent the spread of communicable infections.

During a telephone interview on 5/1/25 at 8:50 AM, the Regional Epidemiologist stated if a resident in a long-term care facility was experiencing respiratory symptoms such as a cough, diarrhea, and/or sore throat,

they should be placed on isolation precautions until the results of a non-rapid test type were received. They stated it was not usually something they talked about with facilities because nursing staff should know to put residents on isolation precautions as soon as symptoms start, or a non-rapid test was obtained for any potential communicable disease. They stated residents experiencing respiratory symptoms and not placed

on isolation precautions was concerning as that was how infection was spread.

During an interview on 5/2/25 at 9:00 AM, Nurse Practitioner #1 stated they were unaware as to what the policy for influenza prevention stated, but as a facility they would want a resident experiencing respiratory symptoms such as a cough and sore throat to stay in their room away from other residents and encourage spacing. They would expect staff to report resident symptoms to their superiors and then follow the proper protocols. They stated staff should be wearing gloves and a mask while caring for residents experiencing respiratory symptoms to stop the spread of infection.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/02/2025 Houghton Rehabilitation & Nursing Center 9876 Luckey Drive Houghton, NY 14744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

During an interview on 5/2/25 at 9:45 AM, [NAME] President of Clinical Services/ Infection Preventionist stated their policy directed that any resident with a suspected upper respiratory infection should be placed on Droplet isolation precautions, best practice would be to initiate as soon as symptoms began. They stated Residents #28, #42, and #67 should have been placed on Droplet isolation precautions as soon as their symptoms started, by the supervising nurse at the time, to mitigate the spread, at least until their swab results were received.

During an interview on 5/2/25 at 11:04 AM, the Director of Nursing reviewed the influenza outbreak policy and stated Residents #28, #42, and #67 should have been placed on Droplet isolation precautions as soon as their respiratory symptoms started, especially since they were all tested for influenza, COVID-19, and respiratory syncytial virus. They should have been placed on precautions within 48 hours of their symptoms starting, to prevent the spread of infection. They stated the floor nurse was responsible for updating the unit manager or supervisor on the resident's symptoms, who should have initiated Droplet isolation precautions until swab results were received.

1. 2. Resident #31 had diagnoses including cellulitis (a common potentially serious bacterial skin infection) of

their right lower limb, morbid obesity, and lymphedema (swelling most often in arm or leg, caused by a lymphatic system blockage). The Minimum Data Set, dated dated dated [DATE REDACTED] documented Resident #31 was cognitively intact, was sometimes understood and understands. Resident #31 was at risk for pressure ulcers, had 1 unhealed pressure ulcer Stage 3 (characterized by full thickness skin loss, extending into the subcutaneous tissue (fat layer) but not reaching muscle or bone), and one venous/arterial ulcer (both types of open sores, often found on the lower legs and feet caused by impaired blood circulation).

Review of the comprehensive care plan revised on 4/22/25, documented Resident #31 had a right anterior skin venous ulcer, Stage 3 pressure ulcer to distal right buttocks related to immobility, occasional urinary incontinence and potential for skin impairment/injury related to fragile skin and history of cellulitis.

Interventions included to administer treatments as ordered, follow facility policies/protocols for the prevention/treatment of skin breakdown.

During an observation of treatment application on 4/30/25 at 9:49 AM, Licensed Practical Nurse #1 with Wound Certified Registered Nurse Assistant Director of Nursing # 1 assisting revealed the following: -Licensed Practical Nurse #1 washed their hands and donned (put on) gloves, removed a border gauze from Resident #31's right distal buttocks, changed their gloves and had not washed their hands, revealing a superficial open area 5 centimeters x 2 centimeters with a small amount of serosanguinous drainage (a common type of wound drainage, a mixture of thin watery, pale red or pink fluid containing a small amount of blood, and a clear yellow fluid called blood serum) present on the dressing. Licensed Practical Nurse #1 cleansed the superficial open area with normal saline and a gauze dressing, changed their gloves and did not wash their hands. They applied zinc oxide as ordered and covered it with a border gauze, changed their gloves and did not wash their hands.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/02/2025 Houghton Rehabilitation & Nursing Center 9876 Luckey Drive Houghton, NY 14744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Licensed Practical Nurse #1 proceeded with treatment #2 located on Resident #31's right lower leg, donned gloves and did not wash their hands. They removed the Coban (self-adherent wrap) dressing, kerlix dressing, the hydrofera blue (a type of wound dressing designed to provide antibacterial protection and promote wound healing) dressing and a part of the moistened calcium alginate (a highly absorbent wound dressing made from alginate, a natural polymer derived from the cell walls of brown seaweed), then used a gauze dressing with normal saline to moisten and pull the remaining calcium alginate from the wound revealing a superficial open wound 8 centimeters x 4.5 centimeters with a moderate amount of serosanguinous drainage and did not change gloves and wash hands, they proceeded to open a new bottle of Dakin's solution with the contaminated gloves, then cleansed the right lower leg wound with Dakin's solution and used a gauze dressing to cleanse the open wound, did not change gloves and wash hands, between removing additional calcium alginate and cleansing the wound and then used a clean gauze dressing to pat dry the wound and had not changed gloves and washed hands between cleansing and drying

the open wound. They changed gloves and did not wash hands prior to applying the new treatment to the wound. Licensed Practical Nurse #1 was observed to wash their hands at the end of the treatment.

During an interview on 4/30/25 at 10:23 AM, Licensed Practical Nurse #1 stated they should have washed their hands after removing the previous dressings and before cleansing the wounds, after cleansing the wounds before applying the treatment, between each treatment site and any time they change their gloves.

They stated they should have removed their gloves and washed their hands prior to touching the Dakin's solution bottle because they contaminated the bottle. They stated changing gloves and washing hands was standard of practice for infection control purposes to prevent cross contamination and promote healing of wounds.

During an interview on 4/30/25 at 10:35 AM, Registered Nurse Wound Certified Assistant Director of Nursing #1 stated they did not notice Licensed Practical Nurse #1 had not washed their hands during the treatment

observation and would have expected them to have changed their gloves and washed their hands before initiating a treatment, after removing an old dressing, after cleansing a wound and prior to initiating a treatment and in between treatment sites. They stated Licensed Practical Nurse #1 should not have touched

the Dakin's bottle with their contaminated gloves because they cross contaminated to the Dakin's bottle and other nurses would touch the bottle with their hands to prepare for the application of the treatment, therefore

they will need to throw it out. They stated the purpose of changing gloves and washing hands was for infection control purposes, to prevent cross contamination and promote healing of wounds.

During an interview on 5/2/25 at 12:37 PM, the Director of Nursing stated they would have expected Licensed Practical Nurse #1 to have washed their hands every time they changed their gloves and at a minimum of at the initiation of a treatment, after removing old dressings, after cleansing a wound, at the completion of a treatment and prior to the initiation of a treatment at another site. They stated changing gloves and washing hands was important for infection control purposes to prevent cross contamination and promote wound healing.

During an interview on 5/2/25 at 12:48 PM, [NAME] President of Clinical Services/ Infection Preventionist stated changing gloves and washing hands was important for infection control purposes and to prevent cross contamination. They stated at a minimum Licensed Practical Nurse #1 should have washed their hands any time they changed their gloves, at the initiation of a treatment, after removing a dressing, after cleansing a wound, and at the completion of a treatment prior to the next treatment site.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/02/2025 Houghton Rehabilitation & Nursing Center 9876 Luckey Drive Houghton, NY 14744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10NYCRR 415.19 (a)(2)(b)(4) 08/27/2025