Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Massena Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A facility failed to supervise residents with wandering and exit-seeking behaviors and did not respond effectively to wander alert alarms. One resident with dementia and severe cognitive impairment exited past the front entrance and was found across the street after staff were distracted assisting visitors. Another resident with stroke-related communication impairment repeatedly left the building alone, crossed to a grocery store or shopping plaza, and was not consistently re-evaluated for out-on-pass status. A third resident with dementia was found in an unsecured administrative area with construction and electrical equipment after a door alarm was cleared and the resident was not immediately located.
A resident meal service issue involved food being served at improper temperatures, with dry fish, room-temperature fruit, and missing beverages on trays. Staff and family reported cold, flavorless meals, tray-ticket mismatches, substitutions, and occasional missing items, while the Unit A2 kitchenette had limited snack stock compared with stated par levels. Interviews also described budget-driven food ordering problems, back orders, and inconsistent oversight of tray accuracy and menu service.
Insufficient food service and nutrition staffing was identified when the facility lacked an on-site FSD to manage kitchen operations, and the person serving as a dietary technician did not have the credentials for that role. Interviews showed the per diem FSD only came in weekly to order food and supplies, the RD worked remotely, and staff described the kitchen as having no management. A resident also reported that dietary staff had not checked preferences or updated the meal plan.
Kitchen sanitation and equipment maintenance failures were observed in the main kitchen. Surveyors found moldy cucumbers in the cooler, a freezer with dripping condensation and ice buildup, soiled utensils, drain flies, heavy debris on equipment and floors, disintegrated wiping cloths, and a steamer oven leaking boiling liquid. The box compactor area was piled with empty boxes, and interviews showed cleaning duties were divided, logs were not being completed, and kitchen cleanliness was not being documented.
A facility failed to maintain a clean, comfortable, and homelike environment on multiple units. Surveyors found strong urine odors, dirty floors and walls, soiled linens, debris, and repeated ceiling leaks with buckets and trash cans catching dripping brown water and broken ceiling tiles. An LPN also reported a mattress stained by urine over time, and no work order was found for replacement.
Controlled Substance Log Signed Before Administration: An LPN signed the narcotic log in advance for scheduled controlled meds for five residents, including opioid and antianxiety doses that were not yet due. The facility policy required accountability and security for controlled substances, but it did not describe the documentation process for administration on the log. The RN unit manager stated the log should be signed only after the med was given, not for the whole shift at the start.
Nonfunctioning Resident Call Bell: A resident’s call bell did not activate the light above the door or alert the nursing station when pressed, even when the surveyor tested it. The resident was observed wet from urine while unable to get assistance through the call system, and a CNA said the light normally indicates a need for help while an LPN reported the resident’s call light had ongoing issues for months and that many unit call lights did not work properly.
Insufficient dietary staffing led to late meal service in the kitchen and on multiple units. Meal trays for Units A1, B2, and C1 arrived well after scheduled mealtimes, with staff reporting call offs, short staffing, and a slow lunch service. The FSD stated the kitchen should function with six staff but was often run with three, and an RN UM noted meals had been late for several days.
Kitchen sanitation and food prep failures were observed throughout the main kitchen. Surveyors found uncovered food left unattended, dirty walls, grease and grime on cooking equipment, standing water and food debris near the dish area, ice buildup in the freezer, and missing ceiling tiles with exposed wires. Staff did not verify sanitizer concentration correctly, did not perform hand hygiene between dishwashing and food service tasks, and prepared pureed baked beans without measuring ingredients or thickener per recipe. No tray line, dishwasher, cleaning, or sanitization logs were available.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
The facility did not attempt alternatives before using a bed rail, failed to assess a resident for safety risks, did not review risks and benefits with the resident or representative, did not obtain informed consent, and did not ensure proper installation and maintenance of the bed rail.
A resident with stroke, anxiety, and impaired cognition reported missing dentures, but the grievance was not resolved promptly and the resident was left without clear updates on the status of the dentures for an extended period. In addition, six residents at a group meeting did not know how to file a grievance, grievance forms were not available, and the facility had no process for anonymous grievances; the grievance log showed only a few entries and the SSW said residents had to report grievances directly to them or contact the Ombudsman for anonymous complaints.
Medication carts and med rooms had multiple storage and labeling failures. An RN was observed preparing meds ahead of time in labeled cups on a cart, expired eye drops remained in use, eye drops and an inhaler on another cart were not properly labeled, one med cart was left unlocked and unattended near residents, and refrigerator temperature logs had missing entries with one refrigerator reading above the required range. Staff stated carts should be locked when not in use and meds should be dated when opened.
Food was not served at palatable, appetizing temperatures during two lunch meal observations. A resident reported the food was not good, portions were too small, items were often missing, and meals were never hot. Observed trays included hot items that were only around 110 to 122 degrees F and milk that was warm, while staff described the food as bland, crunchy, missing cheese, and not appetizing. Multiple staff also reported ongoing resident complaints that meals were cold, tough to chew, and did not taste good.
Staff, including an LPN and several CNAs, were observed feeding residents while standing and addressing them with terms like "honey" and "feeders" instead of their preferred names, contrary to facility policy requiring seated feeding and respectful address. Staff interviews confirmed knowledge of proper procedures but cited lack of chair access and uncertainty as reasons for noncompliance.
A resident with cognitive capacity and a health care proxy was not fully informed about a chest x-ray ordered after a fall and low O2 sat. The resident told the x-ray tech they did not know why the test was being done, and there was no documented evidence the resident was told the reason for the x-ray or the results before asking again days later; staff had instead notified the family/health care proxy.
Two residents were denied reasonable access to private telephone use. One resident with a fractured arm, anxiety, and wheelchair dependence had a room phone with no dial tone and could not reach family because the alternate phone location was inaccessible. Another resident with anxiety, MDD, and moderate cognitive impairment had no room phone and had to use the nurse’s station phone, where conversations could be overheard by staff and other residents.
Failure to Follow Care-Planned Fall and Transfer Assistance Interventions: A resident with a BKA and repeated falls was care planned for a left enabler bar, but observations showed the bed had no enabler bar in place even though staff documented it as an intervention. Another resident with morbid obesity, hemiplegia, and severe cognitive impairment was care planned for extensive assist of 2 with a standing Hoyer for toileting and transfers, but CNAs were observed transferring the resident with only one staff member present and staff acknowledged the care plan was not followed.
Failure to provide person-centered behavioral health care and services for two residents. One resident with severe depression had repeated requests for psychotherapy, an ED visit for suicidal ideation, and no documented psych follow-up or care plan addressing the mental health history or suicidal thoughts. Another resident with schizophrenia, bipolar disorder, and major depression had only psychotropic-medication-focused interventions, with no documented mental health care plan, PASRR Level II record, or nonpharmacological supports.
Meal trays did not match resident meal tickets and care plans for several residents. Three residents who were supposed to receive Mighty Shakes did not get them, one resident’s tray was missing multiple ordered items, and an LPN, RN, SLP, dietary staff, and the FSD confirmed the tray line was responsible for accuracy. Another resident with dysphagia and a G-tube was ordered a mechanical soft diet with ground meats and no bread, yet buns were placed on the tray on two occasions and had to be removed after the resident pointed it out.
A resident with PVD, diabetes, obstructive/reflux uropathy, severe cognitive impairment, and an indwelling catheter did not receive timely follow-up with urology, dentistry, or podiatry. The chart showed a missed urology cystoscopy reschedule after refusal, no documented dental follow-up after a consult, and no podiatry follow-up after a recommendation to return in 2-4 months. Staff interviews confirmed the follow-up appointments were not reliably entered or tracked, and the HCP reported ongoing catheter-related problems, sores, sepsis, and UTIs.
An LTC facility failed to maintain an effective infection prevention and control program for a resident with MRSA at a gastrostomy site. An LPN performed gastrostomy care while wearing gloves but not a gown, despite posted precautions calling for both PPE items. The facility also had infection control policies that were not reviewed annually, and staff reported the resident’s precaution sign had been incorrect until it was later changed.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, did not receive timely antibiotic treatment for a wound infection as recommended by an outside wound consultant. The delay was due to a lack of timely communication and follow-up between nursing staff and the attending physician, resulting in a failure to obtain a physician order for doxycycline. Despite the delay, the resident did not experience negative effects.
Failure to Supervise Residents With Wandering and Exit-Seeking Behaviors
Penalty
Summary
The facility failed to provide proper supervision to residents with wandering or exit-seeking behaviors, and failed to respond appropriately to wander alert alarms, resulting in residents accessing unsafe areas or leaving the building undetected. The report identifies Immediate Jeopardy and Substandard Quality of Care for three residents who were reviewed. Facility policies required staff to verify out-on-pass status, notify nursing supervision when a resident attempted to leave without authorization, and initiate a structured elopement response including paging, searching the building, and searching the surrounding area. One resident had dementia, anxiety, depression, severe cognitive impairment, wandering behaviors, and a history of falls. The resident’s care plan identified elopement risk and included use of a wander alert device. On one occasion, the resident exited the building into the parking lot and walked across the street after staff were distracted at the front entrance while assisting visitors with the elevator code and responding to alarms. A visitor found the resident outside asking for a ride, and staff later retrieved the resident from across the road. Family stated they were not told the resident had made it across the street until later. A second resident had stroke-related communication impairment, weakness, and a history of wandering, agitation, exit-seeking, and attempts to leave for food or shopping. Although the resident had been assessed for out-on-pass with a responsible party, the record did not show a re-evaluation before the resident left alone on multiple occasions. The resident walked out of the building, crossed the street to a grocery store or shopping plaza, and was found by staff after leaving without notifying the nurse or signing out. Staff interviews described the resident as repeatedly taking advantage of busy front desk coverage, removing a wander alert device, and leaving without one-to-one supervision or other consistent monitoring. A third resident had dementia with agitation, major depression, significant cognitive impairment, and wandering behaviors. The resident was identified as an elopement risk and wore a wander alert device. On one occasion, the resident was found in an unsecured non-resident administrative area where construction and electrical equipment were present and the floors were unfinished. The investigation documented that a door in that area was not locking properly, staff had turned off an alarm, and the resident was able to enter the area before being located by staff. Interviews also described that staff were not always sure where the alarm was coming from and that the resident wandered frequently throughout the building.
Meals Served at Improper Temperatures and Incomplete Snack Availability
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional needs during two meals and in one kitchenette. During the lunch meal observation, a resident’s tray was tested and found to contain fish at 118 degrees Fahrenheit, mashed potatoes at 121 degrees Fahrenheit, mixed vegetables at 134 degrees Fahrenheit, fruit cup at 70 degrees Fahrenheit, and coffee at 128 degrees Fahrenheit. The fish was described as dry with a jerky-like texture, and the fruit cup was room temperature. Staff also stated that beverages were normally served on trays, but they were not served on the lunch trays that day. During the dinner and lunch-related interviews, staff and family described repeated problems with meal quality and tray accuracy. A resident’s family stated meals were late, not palatable, and hot meals were always cold, with few options available. An LPN stated hot food was served cold, cold food was served at room temperature, meal tickets did not usually match the meal tray, and missing items were usually condiments. A CNA stated residents complained that food was cold when it should be hot, lacked flavor, and that meal tickets sometimes did not match what residents received. The LPN also stated that pureed diets were sometimes sent as regular consistency trays, diabetic residents received sugary items, and the kitchen sometimes substituted menu items when it did not have the ordered food. The Unit A2 kitchenette was also observed to have limited snack availability compared with the facility’s stated snack par levels. On one observation, the kitchenette contained graham crackers, peanut butter crackers, mini marshmallows, pudding cups, peanut butter, bread, English muffins, hot chocolate packets, tea, condiments, and several refrigerated and frozen items including thickened liquids, milks, shakes, sandwiches, sherbert, and ice cream. On a later observation, the kitchenette contained only a small amount of ice cream/sherbert, graham crackers, and peanut butter. Staff interviews stated snacks were limited, sometimes unavailable, or still frozen when brought to the unit, and that residents had complained they never had snacks. The Food Service Director, former Food Service Director, Administrator, and Registered Dietitian all described ordering and menu issues, including budget-driven reductions, back orders, substitutions, and lack of oversight of tray accuracy and meal service.
Insufficient Food Service and Nutrition Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietitian. The facility assessment documented that the former Food Service Director was on medical leave and that a per diem Food Service Director was being used. The current staff list identified the Nutrition Assistant as a dietetic technician, and the job descriptions showed that the Food Service Director role required leadership and direct supervision of dietary staff, while the dietetic technician role involved nutritional care planning, resident interviews, meal intake monitoring, and verification of diet orders. During interviews, multiple staff and residents described the absence of on-site management in the kitchen. The Ombudsman Coordinator stated food was the biggest issue at the facility and that the kitchen staff had no management. A resident stated no one from dietary had come to check preferences or update the meal plan. A staff member stated there had been no kitchen manager for at least two weeks, and that the per diem Food Service Director only came in to train new kitchen managers and order food and supplies. Another dietary staff member stated the night shift usually had only two or three staff total. Additional interviews showed that the per diem Food Service Director was only in the building once a week to review inventory and order supplies and food, and did not oversee the kitchen or handle meal preparation, cleaning, or meal accuracy. The former Food Service Director stated they had not worked in the facility since December 2025 and that the per diem director was only responsible for ordering food. The Registered Dietitian stated they provided remote support, while the Administrator stated they were managing day-to-day kitchen operations and that the Nutrition Assistant was acting as the dietary technician despite not having certifications or credentials in nutrition. The report also states the facility had a registered dietitian on record who worked remotely and was never seen in the facility.
Kitchen sanitation and equipment maintenance failures
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices in the main kitchen. Survey observations and interviews documented spoiled food in the walk-in cooler, including moldy cucumbers, along with an unclean walk-in freezer that had water dripping from the condenser, ice built up on boxes and the floor, and food stored in a freezer truck behind the facility because the freezer had been repaired and then began dripping again. The utensil container was soiled, there were numerous drain flies by the juice system and dishwashing areas, garbage can bases were heavily soiled, and there was built-up food debris in reach-in refrigerators, freezers, and under and behind kitchen equipment. The kitchen also had inadequate sanitation supplies and equipment issues. Surveyors observed only two sanitizer buckets for the entire kitchen, one containing a very soiled cloth and liquid, and the wiping cloths were disintegrated. Dietary Aide #36 stated staff brought in their own cloths for wiping and cleaning because the facility cloths were disintegrated. The steamer oven door seal was in disrepair and boiling liquid leaked out consistently while in use, and the floor drain did not have a smooth transition from the tile to the grate, causing liquid to puddle instead of draining properly. The box compactor room was also observed with boxes piled in a semi-circle around the machine to the height of the compactor. The Environmental Services Director stated the box compactor had been out of service for approximately a week and a half and had been repaired, but empty boxes had built up around it. Interviews further documented that kitchen cleaning responsibilities were divided among staff, that cleaning logs were not being completed, and that there was no direct supervisor for the kitchen. The Administrator stated kitchen cleanliness was their responsibility at the time and that staff were not documenting cleaning tasks.
Unclean Environment, Urine Odors, and Ceiling Leaks
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on three of four resident units reviewed, including A1, A2, and C2. Surveyors observed strong urine odors on A1, A2, and C2 units, along with unclean walls and floors. The facility’s policy stated that staff and management should maximize a personalized, homelike setting with a clean, sanitary, orderly environment and pleasant, neutral scents, but cleaning logs requested for C1 and B2 units, the Daily Room Cleaning Log for A2, and Terminal Cleaning Logs for the A2 common areas were not provided. On C1 unit, surveyors observed trails of a brown substance near the nurse’s station, white marks on the baseboards and walls across from Central Bath 109, soiled linens and a garbage bag near a shower area, discoloration on the shower floor and ramp, debris and discoloration in a resident room, and a dried brown substance on the hallway floor with footprints. The hallway and nurse’s station area also had a strong urine odor. On A1 unit, there was a strong urine odor immediately upon entry, and on C2 unit there was a strong urine odor at the nurse’s station. On A2 unit, surveyors repeatedly observed a strong urine odor and active ceiling leaks. Buckets and trash cans were placed in hallways to catch dripping water from missing or damaged ceiling tiles, including brown water and broken ceiling pieces, and no yellow hazard sign was present at one point. The Director of Environmental Services stated the air conditioner compressor was leaking in the ceiling and along duct work, and that water in catch receptacles should be drained daily. Later observations showed continued dripping, foul odor from collected water, and a resident room with a stained ceiling and a mattress without linens that had a large yellow-brown stain. An LPN stated the mattress had been stained by urine over time and that no work order had been found for replacement.
Controlled Substance Log Signed Before Administration
Penalty
Summary
The facility failed to ensure a system of records and accounts of all controlled drugs was maintained for five residents. During an observation and interview, the Unit C1 narcotic medication book was requested, and an LPN stated it would be wrong because all narcotic medications had already been signed off for the entire day. The narcotic book had been signed in advance for scheduled controlled medications for five residents, including oxycodone/acetaminophen, clonazepam, hydrocodone/acetaminophen, and tramadol doses that were not yet due at the time of the observation. The facility policy on controlled substances stated that a record of all controlled substances would be maintained to ensure accountability and security, including receipt, usage, wastage, return to pharmacy, disposition, and reconciliation of controlled medications, but it did not describe the process for documenting administration on the log. During interviews, the LPN stated the narcotic book should be signed when medications were given and not ahead of time, and the RN unit manager stated nurses were taught to check counts, compare the book and medication card, administer the medication, and then sign the narcotic book, not to sign the whole shift at the beginning.
Nonfunctioning Resident Call Bell
Penalty
Summary
The facility failed to ensure that a working call system was available in a resident’s room, including the bedside and bathing/toilet communication system required by facility policy. Resident #9’s call bell did not function as designed, and the call light above the door did not illuminate when the resident pushed the button. On 05/05/2026 at 8:43 AM, the resident was lying in bed and stated they were wet from urine, then pushed the call bell button three times without the light illuminating; the surveyor also pushed the button and the light did not illuminate, and no audible beeping was heard at the nursing station. The same problem was observed again on 05/05/2026 at 2:45 PM, 05/06/2026 at 9:33 AM, and 05/07/2026 at 11:24 AM, when the resident’s call bell was pushed and the light above the door did not illuminate and no sound was heard at the nursing station. During an interview on 05/07/2026 at 11:30 AM, a CNA stated they knew a resident needed assistance when the call light illuminated and said sometimes the button had to be pushed really hard; they were not aware the resident’s call bell was not working. An LPN stated on 05/08/2026 that many call lights on the unit did not work properly and that Resident #9’s call light had issues since 08/2025, had been fixed once, and then continued to have problems. The Director of Environmental Services stated the call bell system should send a signal to the nursing station and that they were not notified the resident’s call bell was not functioning.
Late Meal Service Due to Insufficient Dietary Staffing
Penalty
Summary
Insufficient support personnel were provided to safely and effectively carry out food and nutrition services in the main kitchen and on Units A1, B2, and C1. The facility’s policy required meals and/or nutritional supplements to be provided within 45 minutes of the resident request or scheduled mealtime, and meals were scheduled at set times for breakfast, lunch, and dinner. The resident census was 138, and the dietary schedule showed multiple staffing shortages during the survey week, including call offs, reduced staffing, and one day with no cook and only one staff member leaving at 10:00 AM. Survey observations showed meal trays for Units A1, B2, and C1 were delivered late, including trays arriving more than an hour after scheduled mealtimes. On one day, Unit C1 hallway trays arrived at 12:44 PM and Unit A1 lunch trays arrived at 1:03 PM; on another day, lunch trays for Unit A1 and Unit C1 left the kitchen at 1:24 PM and 1:36 PM, with the dining room cart leaving at 1:50 PM. Overhead pages also documented late tray arrivals for Unit B2 breakfast and Units A1 and C1 lunch trays. Staff interviews confirmed the kitchen was behind because of call ins and short staffing, with the Food Service Director stating the kitchen should function with six staff but was usually run with three, and that lunch was very slow. A CNA reported concern about whether a resident could receive lunch before an appointment, and an RN Unit Manager stated meals had been late for the past few days and residents deserved to have meals on time.
Kitchen sanitation and food preparation failures
Penalty
Summary
The main kitchen was observed to have multiple sanitation and food handling deficiencies during the recertification survey. Surveyors found an uncovered pan of blueberry cobbler left unattended on a wheeled cart, dirty kitchen walls, grease buildup on fryers, grime on ovens and the stove top, and caked debris on the floors under the cooking equipment. The freezer condenser was dripping, and there was a 2-foot by 2-foot area of ice buildup on the freezer floor dripping between metal racks that held boxed frozen food. Missing ceiling tiles with exposed wires were also observed in the area between the dishwasher and drying racks. Additional observations showed standing water and food debris between the dish machine and drying racks, a dirty wall behind the 3-bay sink, standing pink liquid in the prep sink, and crusted debris on the stove, oven, fryer, and walls behind large kitchen equipment. The steam table contained food left uncovered and unattended after meal service. During interview, the Food Service Director stated they were unsure whether the chemical concentration in the 3-bay sink had been checked and did not know where the test strips were located. Dietary staff washing dishes stated they had never checked the chemical concentration and did not know where the strips were located. When test strips were later found, they were used in the soapy water bay rather than the sanitizer bay. During lunch preparation and service, a Dietary Aide washed dishes while wearing the same gloves used during food preparation, then later returned to food preparation without hand hygiene being performed between dishwashing and food service tasks. The aide prepared pureed baked beans without measuring the amount of beans, hot water, or thickener, despite the Food Service Director stating that each pureed item had a recipe requiring specific measured amounts. The thickener bag contained a paper cup and a blue plastic coffee mug used as scoops, which the Director stated were not supposed to be there. The report also noted there were no temperature logs for the tray line or dishwasher and no kitchen cleaning or sanitization logs.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Follow Bed Rail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow required procedures before the use of a bed rail. Specifically, the facility did not attempt alternative approaches prior to bed rail use, did not assess the resident for safety risks, and did not review the risks and benefits of bed rail use with the resident or their representative. Additionally, informed consent was not obtained, and there was no evidence that the bed rail was correctly installed and maintained.
Delayed grievance resolution and lack of grievance access information
Penalty
Summary
The facility did not ensure prompt grievance resolution for Resident #138, who had diagnoses including stroke and anxiety disorder, moderately impaired cognition, and no natural teeth or tooth fragments. The resident was admitted with top dentures, and the care plan documented upper dentures and staff assistance with oral care. On 5/15/2025, the resident reported their dentures were missing, and the missing item report documented that CNAs were told to watch for them, the RN Unit Manager placed the resident on the dentist list, and follow-up would occur at the end of August after the resident was seen. During an interview on 8/11/2025, the resident stated the facility lost her dentures, that she had spoken to the social worker but had not gotten anywhere, and that she did not know the status of finding or replacing them. The dentures were not located until 8/15/2025, when they were found in the resident’s room/drawer after being missing for more than a month. The facility also did not provide grievance information to six residents present at a group meeting. Those residents did not know how to file a grievance, grievance forms were not available to residents, and the facility lacked a process for residents to file an anonymous grievance. The Administrator stated the grievance log had only five entries for 2024 and 2025 and that the grievance process had been reinstated because the facility had not been using it. The Social Service Director stated residents wanting to file a grievance had to report directly to them, and residents wanting to file an anonymous grievance would have to contact the Ombudsman. The facility policies stated residents were to be afforded the right to voice grievances without fear of discrimination or reprisal and were to receive contact information for filing grievances or complaints concerning suspected violations of nursing facility regulations.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles in multiple medication areas, including one medication cart on Unit A2, one on Unit B2, one on Unit C1, and medication rooms on Units A and C. The facility’s policy required medications to be stored safely and securely, with refrigerator temperatures maintained between 36 and 46 degrees Fahrenheit and medications checked regularly for expiration and deterioration. Surveyors found missing temperature documentation on the August 2025 medication refrigerator logs for Unit A2 and Unit C1, and the Unit A2 medication refrigerator was observed with ice buildup in the freezer and a temperature of 50 degrees Fahrenheit. On Unit A2, the medication cart contained multiple prefilled medication cups with whole and crushed medications, and one cup had a small piece of paper with a resident name and time written on it. Latanoprost eye drops for one resident were opened on 6/1/2025 and expired on 7/1/2025, yet remained in the cart. During interview, an RN stated they used the time before medication administration to place residents’ medications in cups in the cart and put their name and the scheduled time on paper, although they had not been trained to do this. The RN also stated they were not sure why the refrigerator temperatures were not reviewed or recorded and were not sure why the expired eye drops remained in the cart. On Unit C1, the medication cart contained Lumigan eye drops that were not labeled when opened and an Arnuity inhaler opened on 7/1/2025 without a documented expiration date. Staff stated eye drops and inhalers should be dated when opened and that the inhaler was good for 6 weeks after opening, expiring on 8/12/2025. On Unit B2, the medication cart was observed unattended and unlocked while residents were nearby and moving around the unit. The DON stated medication carts should be locked when not in use, medications should not be prepared in cups ahead of time, and refrigerator temperatures should be monitored twice daily by day and night shift staff.
Food Served at Improper Temperatures and Unappetizing Quality
Penalty
Summary
The facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature during two lunch meal observations. During an interview, one resident stated the food was not good, the portions were too small, items were often missing, and the food was never hot. On 8/11/2025 at 12:29 PM, a resident's meal tray was tested in the presence of a CNA, and temperatures were measured at 122.4 degrees Fahrenheit for hot pork sandwich with gravy, 63.3 degrees Fahrenheit for milk, and 117.8 degrees Fahrenheit for mashed potatoes with gravy. The pork and potatoes were described as bland and not hot, and the milk was warm. During another meal observation on 8/13/2025 at 12:51 PM, a resident's tray was tested in the presence of the MDS Coordinator, and temperatures were measured at 110.5 degrees Fahrenheit for a cheeseburger on a bun, 65.8 degrees Fahrenheit for milk, 127.9 degrees Fahrenheit for baked beans, and 127.6 degrees Fahrenheit for coffee. The MDS Coordinator stated the cheeseburger did not look appetizing, noting it was missing cheese and appeared half brown, half dark brown, and crispy looking. The burger was crunchy, the oatmeal cookie was too hard to bite, and the milk was warm. Additional staff interviews reflected repeated resident complaints that the food did not taste good, was cold, and was hard to chew, and the Food Service Director stated temperatures were not documented and that hot food should be over 145 degrees Fahrenheit.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
Surveyors observed that staff failed to uphold residents' rights to dignity and respect during meal service on Unit A2. Specifically, a Licensed Practical Nurse and several Certified Nurse Aides were seen feeding residents while standing, contrary to facility policy which requires staff to be seated at eye level to promote socialization and a dignified dining experience. Staff also addressed residents using terms such as "honey" and referred to them as "feeders" rather than by their preferred names, which is inconsistent with the facility's policy and training on maintaining resident respect and dignity. Interviews with staff confirmed awareness of the proper procedures and the importance of addressing residents appropriately, yet staff admitted to using pet names and standing while feeding due to lack of access to chairs or uncertainty about protocol. The facility's policy emphasizes providing care that bespeaks dignity, respect, and compassion, and requires residents to be addressed in an adult manner by their given names. Despite this, the observed actions and language used by staff did not align with these standards, resulting in a deficiency related to the residents' right to a dignified existence.
Resident Not Fully Informed of Chest X-Ray Order and Results
Penalty
Summary
Resident #53 was not fully informed of a chest x-ray order or the results of the test, despite being cognitively intact and documented as having decisional capacity for medical decisions. The resident had diagnoses including atrial fibrillation, hypertension, and heart failure, and the 5/26/2025 MDS indicated the resident was able to make themself understood and understood others. The resident also had a health care proxy naming their child, effective only if the resident became unable to make decisions, but the capacity evaluation dated 5/20/2025 documented the resident had decisional capacity. After a fall on 8/10/2025, the resident had reopened sutures to the right eyebrow and an oxygen saturation of 88 percent without oxygen. A nurse practitioner ordered a chest x-ray for desaturation, and the imaging was completed the next day. During the x-ray, the resident asked the technician why it was being done and stated they did not know they were getting a chest x-ray. The radiology report was available later that day and was initialed by the nurse practitioner and unit manager, but there was no documented evidence the resident was informed of the order or the results before 8/13/2025, when the resident again asked why the x-ray had been done and was told it was to check for pneumonia and that the results were okay.
Residents Lacked Private and Reasonable Access to Telephones
Penalty
Summary
The facility did not ensure residents had reasonable access to a telephone and a private place to make calls without being overheard for two residents. The facility policy stated residents were to have easy access to telephones and a place where calls could be made without being overheard. Resident #69 had diagnoses including a fractured left arm and anxiety, with intact cognition, partial/moderate assistance needed for most ADLs, functional limitation of one arm, and use of a manual wheelchair with assistance. During observation and interview, the resident’s room phone had no dial tone, and the resident stated they were upset they could not reach their family and could not get to another phone because of their wheelchair use and arm cast. Staff later confirmed the wall jack was dead and had been reported to maintenance, and the DON observed the resident being taken to another room to use a working phone. Resident #126 had diagnoses including anxiety and major depressive disorder, with moderate cognitive impairment and the ability to make themself understood and understand others. During observation and interview, the resident stated they did not have a phone in their room and had to use the telephone at the nurse’s station, where they could not have private conversations with family because staff and other residents were around. Staff interviews confirmed the resident did not have a phone in the room, used the desk phone at the nurse’s station, and could not have a private conversation there because the area was busy and high traffic. Maintenance staff also stated every resident room was supposed to have a phone, but they were not sure whether every room did and were unaware that this resident did not have one or that the jack in the room was broken.
Failure to Follow Care-Planned Fall and Transfer Assistance Interventions
Penalty
Summary
The facility did not ensure that residents received the supervision and assistance devices identified in their care plans to prevent accidents. During the recertification survey, surveyors found that Resident #22, who had a right below the knee amputation, diabetes, intact cognition, limited functional mobility of one leg, and dependence for transfers, had repeated falls and was care planned for a left enabler bar for positioning and bed mobility. Although the care plan, device rail assessment, and care instructions all documented the enabler bar, observations on multiple occasions showed no enabler bar on the resident’s bed. Resident #22’s record showed several incident reports in early August 2025 in which the resident was found on the floor after attempting to self-transfer, reposition in bed, or move near the bathroom. The resident stated they had fallen several times because staff did not come timely when they rang their call bell, and they reported being told by the DON that an enabler bar would be placed on the bed, but it was not. Staff interviews confirmed that the resident was care planned for enabler bars, that the intervention should have been followed, and that the bed did not have the enabler bar in place. Other staff stated the facility did not use enabler bars because they considered them a restraint. The facility also did not follow the care plan for Resident #83, who had morbid obesity, difficulty walking, right-sided paralysis after a stroke, severe cognitive impairment, and dependence for transfers. The resident’s care plan and care instructions required extensive assistance of two staff with a standing Hoyer for toileting and transfers. Survey observations showed CNA staff transferring the resident with only one staff member present, including toileting and transfer activity in which no second staff member was observed. Staff interviews confirmed that the resident was transferred by one person despite the care plan requiring two, and staff acknowledged they knew they were not supposed to do so but were short staffed. Other staff stated the resident required two-person assistance for safety and that all residents requiring a mechanical lift were an assist of two.
Failure to Provide Person-Centered Behavioral Health Care Plans and Follow-Up
Penalty
Summary
The facility did not ensure that two residents received necessary behavioral health care and services to maintain their highest practicable physical, mental, and psychosocial well-being. The cited deficiency involved Resident #18 and Resident #6, both of whom had significant mental health histories and psychotropic medication use, but whose records did not show person-centered behavioral health care plans with measurable interventions addressing their diagnoses, history, and nonpharmacological supports. Resident #18 had diagnoses including recurrent severe major depressive disorder, stroke, and congestive heart failure, and the record showed moderately impaired cognition. The resident repeatedly told the psychiatric nurse practitioner they wanted to resume psychotherapy with a former counselor and wanted updates on the referral status, but the record did not show documented follow-up to secure therapy. After an emergency department visit for suicidal ideations, the resident returned to the facility, but there were no physician orders for psychotherapy consultation and no documented psychiatric nurse practitioner, psychotherapy, or social work follow-up related to the suicidal ideation event. The resident’s care plan addressed psychotropic medications, but there was no documented evidence that it addressed the resident’s mental health diagnoses, history, suicidal ideation, or nonpharmacological interventions. Resident #6 had diagnoses including schizophrenia, bipolar disorder, and recurrent severe major depressive disorder without psychotic features, and the MDS documented moderately impaired cognition and symptoms of depression. The care plan addressed psychotropic medications, but there was no documented care plan for the resident’s mental health diagnoses, history, or nonpharmacological interventions. The record also did not contain the PASRR Level II assessment that was referenced in the resident’s file, and there was no documented care plan reflecting a Level II review for serious mental illness. Interviews with staff confirmed that mental health care plans were not in place for these residents and that follow-up and documentation practices were inconsistent with the residents’ behavioral health needs.
Meal Trays Did Not Match Ordered Diets and Supplements
Penalty
Summary
The facility did not ensure that planned menus and meal tickets were followed for several residents during the recertification survey. Residents #69, #98, and #148 were each supposed to receive Mighty Shakes with lunch and dinner, but observations showed the shakes were missing from their trays. Resident #98 stated trays were always wrong and that they never received Mighty Shakes. Resident #69’s tray was also missing the shake, and Resident #148 was observed without the Mighty Shake and, on another meal observation, without several other items listed on the meal ticket, including boiled egg, vegetable soup, and sweet potato fries. Resident #148 stated they would have eaten the egg salad, boiled egg, and soup if provided, and said they would have liked the sweet potato fries and soup. Staff interviews confirmed that Mighty Shakes were intended for residents with poor intake, weight loss, wounds, or higher protein needs, and that Residents #69, #98, and #148 had all been assessed to receive them. The RD stated the shakes were expected to be on the trays if recommended, but was unsure why the kitchen did not place them there. The FSD and dietary staff stated tray line staff were responsible for matching trays to meal tickets, but also reported that Mighty Shakes were not on trays that week because staff did not know where to locate them, and that some menu items such as sweet potato fries were listed even though they were not available from the vendor. Resident #8 had diagnoses including dysphagia and a gastrostomy tube, and the care plan directed a mechanical soft diet with ground meats and no bread. Despite this, meal observations showed a cheeseburger on a bun on the resident’s tray on two occasions. The resident told staff they were not allowed to have bread, and staff removed the bun after the resident pointed it out. The RN, LPN, SLP, dietary aide, and FSD all confirmed that buns were considered bread and should not have been on the tray, and the FSD stated there was no formal process for ensuring trays were accurate.
Missed Specialist Follow-Ups
Penalty
Summary
The facility failed to obtain outside professional services in a timely manner for one resident who had diagnoses including peripheral vascular disease, obstructive and reflux uropathy, and diabetes, and who had severely impaired cognition and an indwelling urinary catheter. The resident’s care plan addressed diabetes and foot care needs, but there was no documented care plan addressing the urinary catheter. The resident’s record showed a dental consult in April 2024 with no follow-up dental consults documented through the survey period, and a podiatry consultation in May 2024 with no documented podiatry follow-up after the recommendation to return in two to four months. The resident also had urology follow-up that was not completed as planned. A urology note in December 2024 documented a planned cystoscopy for urinary retention and recurrent UTIs, but the resident refused the procedure and was to be rescheduled in four weeks. There was no documented evidence that the follow-up urology appointment was rescheduled. A hospital discharge summary in April 2025 documented a referral to urology for recurrent UTIs, but no urology follow-up was documented after that referral. The resident’s health care proxy stated the resident was not seen by the dentist, podiatrist, or urologist as recommended and reported ongoing catheter-related problems, sores, sepsis, and UTIs. Staff interviews indicated the follow-up process was not reliably completed. An LPN stated CNAs identified residents needing dental or podiatry visits and the information was sent to the Unit Manager or Medical Records/Transportation. The Unit Manager stated many follow-up appointments had not been entered when they took over and that they were reviewing residents to identify specialist visits that had been missed. The Nurse Practitioner stated urology wanted the catheter to remain in place until follow-up, but the urology follow-up had fallen through the cracks. Medical Records and Transportation staff stated they relied on nursing to review appointment paperwork and schedule needed follow-ups, and they were unaware why the resident’s cystoscopy had not been rescheduled.
Infection Control Program and PPE Noncompliance
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident reviewed. Resident #8 had diagnoses including gastrostomy status, was cognitively intact, required partial/moderate assistance with most activities of daily living, and had a feeding tube. The resident’s 7/27/2025 wound culture from the gastrostomy site was positive for methicillin-resistant staphylococcus aureus (MRSA), and the comprehensive care plan documented MRSA at the gastrostomy tube site with interventions including contact precautions and use of gown and gloves when changing contaminated linens. During an observation, an LPN entered the resident’s room to perform gastrostomy site care after an enhanced barrier precaution sign was posted outside the room. The LPN put on gloves, removed the dressing with brown drainage, cleansed the area, and then removed the gloves and disposed of them, but did not wear a gown while performing the care. The sign outside the room directed staff to see the nurse before entering and to wear gloves and a gown. The LPN later stated they did not wear a gown because the sign outside the door was incorrect, and after reviewing the record stated they should have worn a gown when completing wound care to the gastrostomy site because it was draining. The facility’s infection control policies were also not reviewed annually to ensure effectiveness and alignment with current standards of practice. The policy documents described infection control practices, routine monitoring and surveillance, and contact precautions requiring gloves when entering the room and gowns when substantial contact with the resident or wound drainage was anticipated. The DON, formerly the Infection Preventionist, stated isolation precautions were implemented based on the provider order and staff were required to follow posted signage, and that signs should be accurate. The Unit Manager stated staff were expected to follow posted signage and that the contact precautions sign for Resident #8 was changed after the incorrect sign was reported.
Delayed Antibiotic Treatment for Resident's Wound Infection
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards and the resident's care plan. The resident, who had diagnoses including diabetes, Stage 3 chronic kidney disease, and peripheral vascular disease, was seen by an outside wound consultant who recommended starting an antibiotic, doxycycline, for a wound infection. However, there was no documented evidence of a physician order for the antibiotic, and the recommendation was not reviewed or acted upon in a timely manner. The delay in reviewing the wound consultant's recommendation and obtaining the necessary order for doxycycline was attributed to a lack of timely communication and follow-up between the nursing staff and the attending physician. The nurse practitioner and registered nurse involved could not recall why the recommendation was missed, and the order was not written promptly. Despite the delay, it was noted that the resident did not experience any negative effects from the lack of timely treatment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Massena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Country Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 24 | 0 |
| United Helpers Canton Nursing Home | 25.4 mi | ★★★★★ | 0 | 0 |
| Alice Hyde Medical Center | 30.6 mi | ★★★★★ | 15 | 0 |
| St Josephs Home | 32.3 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.