Cycle 1
Health 2025-05-02 · Fire 2025-05-02
8 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Houghton, NY
Houghton Rehabilitation & Nursing Center
2-star overall rating with 2-star inspections with $65,052 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
9876 Luckey Drive, Houghton, NY
(585) 567-2207
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1980-09-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,298
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.53
Baseline 18.65% · Performance 21.19% · Measure score 0.53 · Achievement 0.53 · Improvement 0
Healthcare-associated infections
4.09
Baseline 6.04% · Performance 6.61% · Measure score 4.09 · Achievement 4.09 · Improvement 0
Total nurse turnover
1.8
Baseline 55.26% · Performance 56.32% · Measure score 1.8 · Achievement 1.8 · Improvement 0
Adjusted total nurse staffing
1.92
Baseline 3.01 hours · Performance 3.62 hours · Measure score 1.92 · Achievement 1.92 · Improvement 1.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.12% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 12.7% · Lower 95% interval 7.28% |
| Discharge to community | 43.19% |
50.57%
7.4 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 32.5% · Lower 95% interval 30.48% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 12 · Denominator 28 |
| Discharge mobility score | 53.57% |
50.94%
2.6 pts better
|
Numerator 15 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 42 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 24.49% |
8.2%
16.3 pts better
|
Numerator 24 · Denominator 98 |
| Staff flu vaccination coverage | 56.12% |
42%
14.1 pts better
|
Numerator 78 · Denominator 139 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 13 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.5 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.4 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.0%
1.1 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.2% · Q3 2.4% · Q4 2.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.5% |
18.5%
6 pts better
|
11.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 10.4% · Q3 15.3% · Q4 10.5% · 4Q avg 12.5% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.1%
0.8 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 4.0% · Q3 6.3% · Q4 3.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
13.5%
0.8 pts better
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 11.1% · Q3 14.1% · Q4 15.5% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.2% |
14.8%
18.4 pts worse
|
16.7%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 34.6% · Q3 31.5% · Q4 32.8% · 4Q avg 33.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
15.1%
4.7 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 7.1% · Q3 12.2% · Q4 3.8% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
15.5%
0.3 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 13.3% · Q3 12.0% · Q4 7.3% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.4%
0.4 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
20.8%
7.3 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 26.4% · Q3 27.4% · Q4 25.5% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.9%
0.6 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.5% · Q3 6.6% · Q4 9.8% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
76.7%
22.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
9.7%
2.9 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 13.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
78.8%
18.8 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
20.6%
1.9 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 20.5% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-31 · Fire 2023-03-31
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-11-22 · Fire 2019-11-22
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-19
E · Potential for more than minimal harm
2023-03-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-16
E · Potential for more than minimal harm
2023-03-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-29
E · Potential for more than minimal harm
2023-03-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-16
E · Potential for more than minimal harm
2023-03-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-16
E · Potential for more than minimal harm
2023-03-31
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-03-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-16
E · Potential for more than minimal harm
2019-11-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-15
E · Potential for more than minimal harm
2019-11-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-19
F · Potential for more than minimal harm
2025-05-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-06-19
F · Potential for more than minimal harm
2025-05-02
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-06-19
F · Potential for more than minimal harm
2025-05-02
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-02
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-19
G · Actual harm
2024-10-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-02-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-04
E · Potential for more than minimal harm
2023-03-31
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-16
E · Potential for more than minimal harm
2023-03-31
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-03-31
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-03-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-16
B · Minimal harm
2023-03-31
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-05-16
B · Minimal harm
2023-03-31
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2023-05-16
D · Potential for more than minimal harm
2019-11-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-11-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-11-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-11-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-01-15
B · Minimal harm
2019-11-22
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2020-01-15
Penalties and ownership
What sits behind the stars
$65,052
2024-10-07
Fine
Fine · fine $65,052
Fine
Ownership
Zagelbaum, Batia
5% Or Greater Direct Ownership Interest · Individual
Beim, Esther
5% Or Greater Direct Ownership Interest · Individual
Walden, Chaya
5% Or Greater Direct Ownership Interest · Individual
Creedon, Teresa
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
Corporate Officer · Individual
Mayhle, Douglas
Operational/Managerial Control · Individual
Sawyer, Chelsea
Operational/Managerial Control · Individual
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#3
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3-star overall rating with 4-star inspections with $8,990 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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