Massena Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Massena Rehabilitation & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 22, 2026

  Based 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. […]

• Actual harm, isolatedF684Jun 28, 2023

  Based on observation, interview, and record review during the abbreviated survey (NY00315847), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed (Resident #7). Specifically, for Resident #7 who developed a diabetic ulcer, treatments ordered were not transcribed; ordered treatments were not implemented; attending physician #17 or nurse practitioner #1 were not notified of worsening wounds; a wound culture was not ordered as recommended, and wound culture results were not reported to the medical provider. Subsequently, the wound worsened, the resident developed osteomyelitis (bone infection) and required treatment with intravenous (IV) antibiotics and a wound V.A.C (vacuum assisted closure). […]

• Actual harm, isolatedF686Jun 28, 2023

  Based on observation, record review, and interview during the abbreviated survey (NY00304851 and NY00315847), the facility failed to ensure a resident 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 2 of 4 residents (Residents #3 and 6) reviewed. Specifically, Resident #3 developed pressure ulcers and treatments were not ordered, transcribed, or administered and pressure relief interventions were not provided. […]

• No harm, potential for more than minimal, widespreadF800May 22, 2026

  Based 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. Findings include:The facility policy Food Temperature, dated 09/2018, documented the policy was to ensure safe and quality food items. The facility would obtain and record temperatures of food items prior to serving the residents. […]

• No harm, potential for more than minimal, widespreadF801May 22, 2026

  Based 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). […]