Massena Rehabilitation & Nursing Center

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide proper supervision to residents to prevent elopement and respond appropriately to wander alert alarms resulting in residents having access to unsafe areas and/or to exit the building undetected for three (3) of three (3) residents (Residents #2, #3, and #4) reviewed. Specifically, on 08/24/2025 Resident #2 had known wandering behaviors, exited the building undetected by staff, and was found by a visitor in the parking lot, asking for a ride. Resident #3, had known exit-seeking behaviors and exited the building undetected by staff on 10/06/2025 and 10/23/2025 and was found across a four-lane highway in a shopping plaza, after an undetermined period of time. [...]

Inspectors wroteBased on observations and interviews (iQIES Intake), the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional needs for two (2) of two (2) meals (the 05/04/2026 lunch and dinner meals) and for one (1) of four (4) kitchenettes reviewed. Specifically, the 05/04/2026 lunch and dinner meals were not served at palatable and appetizing temperatures, were not flavorful, and had missing food items; and the Unit A2 kitchenette was not stocked with sufficient snack items available to residents.

Inspectors wroteBased on observation, interview, and record review (iQIES intake 2793248), the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. Specifically, the facility did not have a Food Service Director to manage the kitchen and food service; the full-time dietetic technician did not have the required credentials for the position of Food Service Director, and the registered dietitian worked remotely and was not available on site. Refer to citations (F800 - Food and Nutrition Services and F812 - Food Safety Requirements).

Inspectors wroteBased on observations and interviews (iQIES Intakes 2607654 and 2985855), the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one (1) of one (1) main kitchen. Specifically, the main kitchen had spoiled food; an unclean freezer; unclean surfaces; a steamer oven was in disrepair; and the box compactor room was piled with empty boxes.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intake 2638730), the facility failed to ensure a clean, comfortable, and homelike environment for three (3) of four (4) resident units (A1, A2, and C2 units) reviewed. Specifically, A1, A2, and C2 units had strong urine odors and unclean walls and floors; and the A2 unit had several trash cans with fluid from a leaking ceiling.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intake 2607654), the facility failed to ensure a system of records and accounts of all controlled drugs was maintained for five (5) of five (5) residents (Residents #37, #38, #39, #40, and #41) reviewed. Specifically, Unit C1 had all the scheduled narcotic medications signed off at the beginning of the day, prior to the medication administration time.

Inspectors wroteBased on observations, record review, and interviews (iQIES intake 2610975), the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (1) of four (4) resident rooms observed. Specifically, Resident #9's call bell did not function as designed.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure sufficient support personnel to safely carry out the functions of the food and nutrition services for the main kitchen and for 3 of 4 units (Units A1, B2, and C1) reviewed. Specifically, meal trays for Units A1, B2, and C1 were delivered an hour after the scheduled mealtimes, and concerns were identified with the effectiveness of meal preparation and other foot and nutrition services. Additionally, deficiencies related to food and nutrition services were identified in the areas of: Menus Meet Resident Needs/ Prepare in Advance/ Followed (F 803); Nutritive Value/ Appearance, Palatable/ Prefer Temperature (F804); and Food Procurement, Store/ Prepare Serve-Sanitary (F 812).

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025- 8/15/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for one (1) of (1) main kitchen reviewed. Specifically, the main kitchen had unclean floors, walls, and equipment, uncovered food, the sanitizer solution in the 3-bay sink was not tested, recipes were not followed for pureed items, a food scoop was left in a thickening agent bag, there was ice buildup in the walk in freezer, there were missing ceiling tiles, hand hygiene was not performed between dish washing and food services, there were no temperature logs for the tray line or the dishwasher, no kitchen cleaning logs, or sanitization logs.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00372537) surveys conducted 8/11/2025-8/15/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for the main lobby area, common areas, and four (4) of four (4) units (Units A1, A2, B2, and C1) reviewed. Specifically, the facility did not maintain comfortable temperatures on nursing units A1, A2, B2, and C1, A2 and B2 dining rooms, and the A1 and C1 atriums; and Units A1, A2, B2, and C1, and the main lobby were unclean and in disrepair.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure prompt grievance resolution for one (1) of one (1) resident (Resident #138) or provide information on how to file a grievance or complaint for six (6) of seven (7) anonymous residents present at the group meeting. Specifically, Resident #138 had missing dentures and did not receive timely follow up on their grievance; and 6 residents present at the group meeting 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.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00357525) surveys conducted 8/11/2025-8/15/2025, the facility did not provide on-going assessment and monitoring of bed rails (side rails) for three (3) of three (3) residents (Residents #4, #30, and #126) reviewed. Specifically, Resident #4 had bilateral bed rails and did not have an order or a comprehensive care plan that included the use of bed rails, regular assessments to ensure the bed rails remained appropriate or documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use; [...]

Inspectors wroteBased on observations and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (3) of four (4) medication carts (Units A2, B2 and C1) and two (2) of two (2) medication rooms (Units A and C) reviewed. Specifically, the Unit A2 medication cart had opened and undated eye drops and multiple prefilled medication cups; the Unit C1 medication cart had opened and undated eye drops and an inhaler; the Unit B2 medication cart was left unattended and unlocked; and the medication refrigerator temperatures on Units A and C were not consistently monitored.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (lunch meals on 8/12/2025 and 8/13/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 8/12/2025 and 8/13/2025.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (IQIES 525144 and 2582064) surveys conducted 8/11/2025-8/15/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for six (6) of six (6) staff (Licensed Practical Nurse #12, and Certified Nurse Aides #22, #51, #52, #53, and #54) observed. Specifically, during meal service on Unit A2 residents were observed being fed by Licensed Practical Nurse #12, and Certified Nurse Aides #22 and #51 while standing; and Licensed Practical Nurse #12, and Certified Nurse Aides #52, #53, and #54 addressed residents as honey and feeders.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure all residents were fully informed of and participated in their treatment, including the right to be fully informed in a language that they can understand of their total health status, including but not limited to, their medical condition, and the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternatives or the option they prefer for one (1) of two (2) residents (Residents #53) reviewed. Specifically, Resident #53 was not informed of a medical order for a chest x-ray nor of the results of the x-ray.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for two (2) of four (4) residents (Residents #69 and #126) reviewed. Specifically, Resident #69 did not have access to a telephone and Resident #126 had to make phone calls at the nurse's station where others could overhear their conversations.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two (3) of seven (7) residents (Residents #22, and #83) reviewed. Specifically, Resident #22 did not have an enabler bar on their bed as care planned; and Resident #83 was transferred with assistance of one and not two as care planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025 the facility did not ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of two (2) residents (Residents #18 and #6) reviewed. Specifically, Resident #18 had an emergency department visit due to suicidal ideations, did not receive follow up from social services or psychology services upon return, did not receive psychotherapy services timely as requested and did not have a person-centered care plan and interventions in place to address their mental health; and Resident #6 did not have person-centered care plan interventions in place to address their mental health.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/112/2025-8/15/2025, the facility did not ensure planned menus were followed for three (4) of thirteen (13) residents (Residents #8, #69, #98, and #148) reviewed. Specifically, Residents #69, #98, #148 did not receive Mighty Shakes (nutritional supplement) as planned; Resident #148 was missing multiple items listed on their meal ticket; and Resident #8 received bread at meals when care planned for no bread.

Inspectors wroteBased on record review and interviews during the recertification survey conducted on 8/11/2025 to 8/15/2025 the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for one (1) of five (5) residents (Resident #1) reviewed. Specifically, Resident #1 was referred to Urology and was supposed to have dental and podiatry follow ups the facility did not follow up on in a timely manner.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, 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 (1) of three (3) residents (Resident #8) reviewed. Specifically, Resident #8 was on contact precautions (used to prevent transmission of pathogens that are spread by direct person-to-person or indirect contact with the resident or environment) and Licensed Practical Nurse #20 changed a gastrostomy tube dressing (a tube inserted in the stomach through the abdomen) without wearing required personal protective equipment. [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00359676), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's wound consultant recommended to start an antibiotic for a wound infection and the recommendation was not reviewed timely.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00331713), the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 6 residents reviewed (Resident #1). Specifically: Resident #1 had a significant weight loss, noted worsening of wounds, decreased appetite/intakes, and a nurse practitioner's recommendation for a dietary consult, and the resident was not reassessed by clinical nutrition staff timely.

Inspectors wroteBased on record review and interview during the recertification survey conducted 12/11/2023 -12/15/2023, the facility did not ensure an infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility water cooling towers had not been tested monthly for Legionella in 2023, and the annual Legionella testing was not completed in 2022.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00319488, NY00326236, NY00319036) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure residents' rights to a safe, clean, comfortable, and homelike environment for 12 isolated areas (C1 unit handicap bathroom, C1 unit bathroom near the lobby, C1 unit central bath room [ROOM NUMBER], C1 unit central bath room [ROOM NUMBER], B2 unit central bath room [ROOM NUMBER], A1 unit resident room [ROOM NUMBER], C1 unit long hall soiled utility room, A1 unit long hall soiled utility room, A1 unit resident room [ROOM NUMBER], second floor main dining area, occupational therapy/physical therapy room, A2 unit central bath room [ROOM NUMBER]). [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00314558, NY00315659, NY00319036, NY00326236, and NY00327075) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 6 of 6 residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner, and for four residents (Residents #22, #38, #89 and #107) reviewed. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 12/11/2023 - 12/15/2023, the facility did not ensure sufficient support personnel to safely carry out the functions of the food and nutrition services for 2 of 4 resident units (Unit A1 and Unit C1), the downstairs dining room and the main kitchen. Specifically, Unit A1, Unit C1 and the downstairs dining room had resident meal trays delivered over one hour after the posted scheduled meal times, and concerns were identified with the effectiveness of meal preparation and other food and nutrition services. Additionally, deficiencies related to food and nutrition services were identified in the areas of: Menus Meet Resident Needs/Prepare in Advance/Followed; Nutritive Value/Appear, Palatable/Prefer Temperature; and, Food Procurement, Store/Prepare Serve-Sanitary.

Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00319036) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety for the main kitchen. Specifically, the main kitchen had undated and outdated food; staff were not wearing hair nets as required; floors, walls and other items were not clean; food scoops were left in sugar and flour bins; there were fruit flies within the kitchen; the three-bay sanitizer strips were expired; and the dish machine water temperatures were out of range.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00315659, NY00327075, and NY00319488) conducted 12/11/2023 - 12/15/2023, the facility did not ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 5 residents (Resident #22) reviewed. Specifically, Resident #22 developed three facility acquired pressure ulcers and: - The pressure relieving air mattress (specialty mattress used to relieve pressure) was not accurately set to the resident's weight. [...]

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 12/11/2023 -12/15/2023, the facility did not ensure 4 of 4 resident assistants (resident assistants #7, #8, #9, and #10) who completed a Nurse Aide Training and Competency Evaluation Program and working in the capacities of nurse aide trainees, were in compliance with the state approved Nurse Aide Training and Competency Evaluation Program. Specifically, the facility received a letter from Centers for Medicare and Medicaid Services dated 10/11/2023, prohibiting the provision of a Nurse Aide Training and Competency Evaluation Program for a period of two years, effective 6/28/2023 through 6/27/2025. The facility hired resident assistants #7, #8, #9, and #10 after the 10/11/2023 prohibition letter to work as nurse aide trainees while waiting to take their nurse aide certification exam.

Inspectors wroteBased on observation, interview, and record review during recertification and abbreviated (NY00319036) surveys conducted 12/11/2023 through 12/15/2023, the facility did not ensure menus were followed for 1 of 2 residents (Resident #95) reviewed. Specifically, during 5 meal observations, Resident #95 had missing menu items from their meal trays, and substitutions were not consistently provided as planned.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00319036) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (12/11/2023 and 12/13/2023 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures.

Inspectors wroteBased on observation and interview during the recertification survey conducted 12/11/2023 - 12/15/2023, the facility did not ensure to post on a daily basis the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent place readily accessible to residents and visitors for 5 of 5 days reviewed. Specifically, the facility did not post the resident census and nurse staffing information daily, as required.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00328448), the facility did not provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles for 3 of 3 employees reviewed (Employees #1, 2, and 3). Specifically, the facility did not complete the required health screenings Employees #1, 2, and 3 and the employees' health records were not completed accurately based on available information and standards of nursing practice. Additionally, Employees #1 and 2's health records included they received the influenza (flu)vaccinations when they had not received them.

Inspectors wroteBased on observation and interviews during the recertification survey conducted from 11/15/21- 11/19/21, the facility failed to maintain a safe, clean, comfortable, and home-like environment for 1 of 4 resident units (Unit B2) and 3 of 29 residents (Resident #3, 2, and 24) reviewed. Specifically, on Unit B2 there were stained, non-waxed, and sticky floors; sticky, unclean walls, baseboards, wall handrails; unclean wheelchairs; and unclean, ripped lift equipment used by residents. Additionally, Unit A2 and B2 did not have enough bath linens for morning care and enough clothing protectors available for use during lunch.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 11/15/21 - 11/19/21, the facility failed to store, prepare, distribute and serve food in accordance with professional standards during the initial kitchen tour on 11/15/21 Specifically, there were multiple undated/unlabeled food items in coolers, employee personal food items in with resident food, soiled soda cans were stored with clean dishes, scoops were in bulk bin items, a plastic container of pizza sauce was not covered fully in the freezer, 1 box of frozen croissants were stored on the floor in the freezer, there were dented cans on a shelf in the dry storage room, and ice buildup in the walk-in freezer.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 11/5/21-11/19/21, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of quality of life for 1 of 3 residents (Residents #59) reviewed. Specifically, Resident #59 was observed lying in bed in their room exposed from the waist down. The resident's door was open, the privacy curtain was not pulled, and the resident was visible from the hallway. Additionally, a housekeeper was in the resident's room cleaning.

Inspectors wroteBased on observation and interview during the recertification survey conducted 11/15/2021-11/19/2021, the facility failed to ensure results of the most recent federal/state survey were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the Statement of Deficiency 3-ring binder in the main lobby did not include results from the last recertification survey on 7/11/19 or the 1/21/21 Focused Infection Control Survey.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00276030 and NY00283911) conducted 11/15/21- 11/19/21, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Residents #14, 37, and 52) reviewed. Specifically, Resident #52 did not receive timely meal assistance at 3 observed meals, Resident #37 was observed wearing the same soiled clothing for 3 days, and Resident #14 did not receive incontinence care as care planned.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00280353) surveys conducted from 11/15/21-11/19/21, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays tested (breakfast). Specifically, food was not served at palatable and safe temperatures for the 11/16/21 breakfast meal.