Massena Rehabilitation & Nursing Center
Inspection Findings
F-Tag F0550
F 0550 Level of Harm - Minimal harm or potential for actual harm
During an interview on 8/13/2025 at 12:07 PM, Certified Nurse Aide #53 stated they had many trainings on different topics including dignity and abuse training. They were not trained to refer to residents as “feeders”. It was not professional to call residents “feeders,” and they should not do it. They were trained not to address residents as “honey” but did it all the time because
they felt it was welcoming.
Residents Affected - Few
During an interview on 8/13/2025 at 12:18 PM, Licensed Practical Nurse #12 stated they tried to use the residents’ last names but that they did use pet names. Residents should not be called honey or sweetie or labeled as a lift or a Hoyer because it was a dignity issue. Residents should be addressed in the way their parents named them. They stated they knew they should be sitting down when feeding a resident, but the chairs were locked up and they did not have access to them. They should not be standing when feeding because it intimidated residents into eating.
During an interview on 8/13/2025 at 12:40 PM, Certified Nurse Aide #51 stated when feeding residents, staff should sit next to them and not stand over them. They stood when feeding Resident #48 because they did not know they were allowed to pull up a chair and there was not a lot of room for the chair. 10 NYCRR 415.5(d)(1)(i)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Massena Rehabilitation & Nursing Center
89 Grove Street Massena, NY 13662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0552
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0552 during a standard health inspection conducted on 2025-08-15.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0576
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0576 during a standard health inspection conducted on 2025-08-15.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure residents have reasonable access to and privacy in their use of communication methods.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0584
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
ajar. The water fountain was leaking and had a red bucket underneath. The alarm in the stairwell was sounding while an unidentified resident and visitor were conversing in the main lobby. -On 8/14/2025 at 12:14 PM, the alarm was sounding in the stairwell in the main lobby. During an interview on 8/15/2025 at 11:50 AM, Maintenance Technician #2 stated their boss quit on Friday, and they were the only person working in the maintenance department. Their job was to respond to broken items. They did not have access to the electronic maintenance request system, so they only knew if something needed fixed if it was verbalized to them. They were aware of broken headboards and footboards throughout the facility, but they were not easy to replace as it took a long time to get replacement parts. They were unaware of the metal coming out of the doorframe in room [ROOM NUMBER] or any holes in the walls in the facility. There was a water leak in the soffit, and they just replaced the ceiling tiles on B2. They were not aware of cracked floor tiles. They were made aware of the broken sinks in rooms [ROOM NUMBERS] on 8/8/2025 but did not know who to call but apparently Environmental Services Aide #28 had called a plumber a couple days ago.
They did not know the shower handle, or the whirlpool tub needed repair. The ice machines were a known issue and to their understanding corporate had ordered new units, but they were waiting for them to come in. They fixed the alarm in the stairwell yesterday as a staff from another facility had come to help them.
They did not know how to fix the front entrance. The water fountain was out of order because the drain needed to be snaked. They fixed wheelchairs if it was reported to them but again, the staff entered requests into the electronic system they did not have access to. Everything in the facility should be in good repair as
it was the residents' right to feel at home. During an interview on 8/15/2025 at 12:23 PM the Administrator stated the Maintenance Director walked off the job the previous Friday. Maintenance Technician #2 did not have access to the electronic work orders, and they were working on that. They stated the floor scrubber was broken. They just stripped and waxed all the common areas. Some of the tiles were replaced and not pretreated. The floors had not been maintained. They stated the housekeeper quit last week on A1 after being educated on how to properly clean. 10NYCRR 415.29(j)(1)
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Massena Rehabilitation & Nursing Center
89 Grove Street Massena, NY 13662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0585
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2025-08-15.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0689
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0700
F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Registered Nurse Unit Manager #36 stated if a resident had mobility bars on their bed, they should have a care plan. They were not aware that resident #4 had mobility bars. They should have had a related care plan prior to 8/15/2025 as well as a consent.2) Resident #30 had diagnoses of kidney disease. The 7/11/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision with most activities of daily living, and did not used bed rails. The 12/23/2022 Comprehensive Care Plan documented an activities of daily living self-care performance deficit.
Interventions included concave mattress and 2 enabler bars.The 4/14/2025 physician order documented bilateral enabler bars to enhance mobility.There was no documented evidence of a bed rail assessment or
a consent for use of the rails.During observations on 8/11/2025 at 10:15 AM and 8/14/2025 at 11:31 AM
the resident had two mismatched bilateral bed rails, both zip tied in an up position at the head of the bed.During an observation on 8/14/2025 at 11:31 AM the resident sat on the edge of the bed and reclined to a lying position without using the bed rails.During an interview on 8/14/2025 at 1:33 AM Certified Nuse Aide #21 stated enabler bars were zip tied if the resident was not care planned to have them. Resident #30's rails were positioned such that they were not in use. If they were in use, they would not be zip tied and would be positioned lower on the bed. They stated the resident did not use the bed rails and after checking the care card, stated the resident was care planned for 2 enablers.3) Resident #126 had diagnoses including stroke with left sided weakness. The 5/11/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, a functional range of motion impairment on one side, required moderate assistance for bed mobility, and did not use bed rails.The Comprehensive Care Plan initiated 9/12/2019 and revised 2/25/2020 documented an activity of daily living deficit.
Interventions included extensive assistance of one for turning and repositioning, a specialized air mattress, and 2 bed enablers.The 10/16/2024 physician order documented enabler bars to enhance mobility.The 4/23/2025 Physical Therapist # 43 discharge summary documented the resident required minimal assistance to perform bed mobility tasks without the use of side rails. There was no documentation for the recommendation for bed rail use.There was no documented evidence of a bed rail assessment or a consent for use of the rails.During an interview on 8/14/2025 at 11:54 AM Certified Nurse Aide #4 stated Resident #126 could move themselves in bed and did not use the bed rails. Their rails were supposed to be strapped but they were not, so the mattress moved all over.During an interview on 8/15/2025 11:42 AM Maintenance Technician #2 stated they installed bed rails if physical therapy told them to. They checked beds for rusty bolts, made sure nothing was broken, and checked the condition of the bed rails. They did not know about entrapment zones, what entrapment meant, and had not had any related training.During an
interview on 8/14/2025 at 2:26 PM Licensed Practical Nurse #20 stated bed rails should be listed in the care plan and be zip tied. They thought if there was not a zip tie then the resident could use the bar as an enabler. They were unsure why a bed with two bars only had one with a zip tie.During an interview on 8/15/2025 at 11:34 AM the Rehabilitation Director stated if a resident needed bed rails, they completed the device form and updated the care plan. They would also update the care plan with any changes. There should not be a rail on a bed if there was no recommendation for it or if it had not been cared planned for.
Zip ties were put in place so the bars could not be put down. If they were down, then they were considered siderails. Zip ties prevented them from becoming a siderail. Any rail that was on a bed should be zip tied.10NYCRR 415.12(h)(1)(2)
Event ID:
Facility ID:
If continuation sheet
F-Tag F0740
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0740 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0761
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-15.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0802
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0802 during a standard health inspection conducted on 2025-08-15.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0803
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0803 during a standard health inspection conducted on 2025-08-15.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0804
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0804 during a standard health inspection conducted on 2025-08-15.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0812
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-15.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0840
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0840 during a standard health inspection conducted on 2025-08-15.
Category: Administration Deficiencies
The facility was found deficient in the following area: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
F-Tag F0880
Federal health inspectors cited MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-15.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of MASSENA REHABILITATION & NURSING CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-10.
MASSENA REHABILITATION & NURSING CENTER in MASSENA, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MASSENA, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MASSENA REHABILITATION & NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.