Inspection Reports for
North Country Nursing & Rehabilitation Center
182 Highland Road, Massena, NY, 13662
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
25.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
404% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey of North Country Nursing & Rehabilitation Center from 8/11/2025 to 8/15/2025 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' nutritional status with unplanned significant weight loss not properly addressed, menus lacking variety and resident input, improper food storage and sanitation practices in the kitchen, inadequate dishwashing sanitization, improper garbage disposal attracting pests, and unclean hallways with odors on Unit 200.
Deficiencies (5)
F 0692: The facility did not ensure residents maintained acceptable nutritional status; Resident #11 had significant unplanned weight loss without timely nutritional interventions or documented physician notification.
F 0803: The facility menus did not reflect resident input and lacked variety, resulting in resident complaints about repetitive starches and limited food options.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; dish machine did not reach sanitizing temperature, food was unlabeled, and hand hygiene was not properly performed.
F 0814: Facility garbage areas were not maintained to prevent pests; old food and trash were found under metal grates near the dumpster with flies present.
F 0921: Unit 200 hallway was unclean with brown, dried, odorous substance on the floor; housekeeping and nursing staff did not consistently clean feces and urine promptly.
Report Facts
Weight loss percentage: 12.8
Weight loss percentage: 9
Weight loss percentage: 5.2
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian #5 | Registered Dietitian | Named in findings related to nutritional status and menu review. |
| Licensed Practical Nurse Unit Manager #6 | Licensed Practical Nurse Unit Manager | Named in findings related to weight loss reporting and physician notification. |
| Physician #7 | Physician | Named in findings related to awareness of resident weight loss. |
| Food Service Director #1 | Food Service Director | Named in findings related to menu planning, food safety, and sanitation. |
| Certified Nurse Aide #9 | Certified Nurse Aide | Named in findings related to resident complaints about food variety. |
| Certified Nurse Aide #10 | Certified Nurse Aide | Named in findings related to resident complaints about food temperature and variety. |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Named in findings related to resident complaints about food. |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Named in findings related to food variety and resident complaints. |
| Housekeeper #2 | Housekeeper | Named in findings related to cleaning responsibilities and hallway cleanliness. |
| Certified Nurse Aide #4 | Certified Nurse Aide | Named in findings related to cleaning feces and urine on floors. |
| Infection Preventionist | Infection Preventionist | Named in findings related to cleaning responsibilities and infection control. |
| Maintenance Director | Maintenance Director | Named in findings related to pest control and dumpster area cleanliness. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey of North Country Nursing & Rehabilitation Center to assess compliance with regulatory standards related to resident care, food service, sanitation, and facility environment.
Findings
The facility failed to ensure menus reflected resident input and variety, served repetitive starches, and lacked specific fruit and vegetable details. Food service safety was compromised due to improper dish sanitization, unlabeled frozen foods, and inadequate hand hygiene. Additionally, the facility did not maintain a clean and odor-free environment in Unit 200 hallways.
Deficiencies (3)
F 0803: Menus did not reflect resident input and lacked variety, with repetitive starches served daily and generic fruits and vegetables listed without specifics.
F 0812: Food was not stored, prepared, distributed, or served according to professional standards; dish machine failed to sanitize properly, food in freezer was unlabeled and undated, and hand hygiene was not performed appropriately.
F 0921: Unit 200 hallway was unclean and had odors, with dried feces smeared on the floor that was not consistently cleaned by housekeeping or nursing staff.
Report Facts
Residents affected: 7
Residents affected: 1
Units affected: 1
Units total: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian #5 | Interviewed regarding menu review and approval | |
| Certified Nurse Aide #9 | Reported resident complaints about repetitive food | |
| Certified Nurse Aide #10 | Reported resident complaints about repetitive food and food temperature issues | |
| Licensed Practical Nurse #11 | Reported resident complaints about repetitive food and bland taste | |
| Food Service Director #1 | Interviewed about menu approval, food preparation, and dish sanitization issues | |
| Licensed Practical Nurse #12 | Reported frequent chicken meals and repetitive sides | |
| Director of Nursing | Acknowledged resident complaints and menu alternates | |
| Dietary Aide #8 | Reported missed sanitizer and dish machine temperature logs | |
| Housekeeper #2 | Responsible for cleaning hallways, reported incomplete cleaning | |
| Infection Preventionist | Described responsibilities for cleaning feces and urine | |
| Certified Nurse Aide #4 | Responsible for cleaning feces and urine on floors |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 24
Date: Aug 15, 2025
Visit Reason
Inspection identified multiple Level 2 deficiencies in standard health and life safety code categories, mostly isolated or widespread, with many corrected by September 18, 2025.
Findings
Inspection identified multiple Level 2 deficiencies in standard health and life safety code categories, mostly isolated or widespread, with many corrected by September 18, 2025.
Deficiencies (24)
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Menus meet resident nds/prep in adv/followed
Nutrition/hydration status maintenance
Safe/functional/sanitary/comfortable environ
Alcohol based hand rub dispenser (abhr)
Discharge from exits
Doors with self-closing devices
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Electrical systems - other
Exit signage
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Illumination of means of egress
Means of egress - general
Portable fire extinguishers
Smoking regulations
Sprinkler system - installation
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Subsistence needs for staff and patients
Utilities - gas and electric
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 15, 2023
Visit Reason
The survey was a recertification and abbreviated survey conducted to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including care planning, provision of adaptive equipment, range of motion care, respiratory care, dialysis care, food and nutrition services, food safety and sanitation, and infection prevention and control practices.
Deficiencies (9)
F 0656: The facility did not ensure a comprehensive person-centered care plan was developed and implemented for Resident #22, specifically regarding the removal of a wheelchair seat belt at meals as planned.
F 0677: Residents #27 and #124 were not provided with adaptive equipment during meals as ordered for multiple days of survey, impacting their ability to eat independently.
F 0688: Residents #36 and #38 did not receive appropriate treatment and services to maintain or improve range of motion and proper positioning, including missing splints and supportive devices.
F 0695: Resident #124 received oxygen at a flow rate lower than the physician's order, risking respiratory distress.
F 0698: Resident #34 did not receive a complete post-dialysis treatment assessment of their fistula by a registered nurse as required.
F 0801: The facility did not employ sufficient staff with appropriate competencies and skills for food and nutrition services; the Food Service Director lacked formal training and a qualified dietician was not onsite.
F 0804: Food was served at unsafe temperatures and was overcooked or burned; milk was served at 63-64°F, and kitchen food safety practices were inadequate.
F 0812: The main kitchen was unclean with food debris and ice buildup; expired milk was stored; hand wash signage was missing near dish machine.
F 0880: The facility failed to maintain an effective infection prevention and control program; staff did not consistently use required personal protective equipment in COVID-19 and droplet precaution rooms, and infection control standards during catheter care were not followed.
Report Facts
Deficiencies cited: 9
Milk temperature: 63
Oxygen flow rate: 3.5
Oxygen flow rate ordered: 4
Milk expiration date: Dec 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director / Kitchen Manager #33 | Food Service Director / Kitchen Manager | Named in relation to lack of formal training and qualifications for food service management |
| Registered Dietician #30 | Registered Dietician | Named as dietician not onsite regularly and providing telecommuting services |
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in relation to improper catheter care |
| Licensed Practical Nurse Unit Manager #3 | Licensed Practical Nurse Unit Manager | Named in relation to oversight of care plan and splint application |
| Licensed Practical Nurse Unit Manager #9 | Licensed Practical Nurse Unit Manager | Named in relation to infection control and resident care |
| Licensed Practical Nurse Unit Manager #13 | Licensed Practical Nurse Unit Manager | Named in relation to dialysis care and infection control |
| Registered Nurse #14 | Registered Nurse | Named in relation to dialysis fistula assessment |
| Certified Nurse Aide #11 | Certified Nurse Aide | Named in relation to improper use of personal protective equipment |
| Certified Nurse Aide #6 | Certified Nurse Aide | Named in relation to infection control and PPE use |
| Certified Nurse Aide #17 | Certified Nurse Aide | Named in relation to meal tray preparation and infection control |
| Certified Nurse Aide #21 | Certified Nurse Aide | Named in relation to infection control and PPE use |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in relation to oversight of meal tray and oxygen care |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Named in relation to dialysis resident care |
| Certified Occupational Therapy Aide #19 | Certified Occupational Therapy Aide | Named in relation to splinting and positioning care |
| Physical Therapy Assistant #23 | Physical Therapy Assistant | Named in relation to wheelchair seat belt care |
| Director of Rehabilitation | Director of Rehabilitation | Named in relation to care plan and therapy oversight |
| Director of Nursing | Director of Nursing | Named in relation to oversight of nursing care and infection control |
| Registered Nurse Staff Educator | Registered Nurse Staff Educator | Named in relation to infection control education |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 12/11/2023 to 12/15/2023 to assess compliance with care and food service standards at North Country Nursing & Rehabilitation Center.
Findings
The facility failed to ensure residents received necessary adaptive equipment during meals, resulting in reduced independence for some residents. Additionally, food was not consistently served at safe and palatable temperatures, and the main kitchen was not maintained according to professional food safety standards, including cleanliness issues and expired milk storage.
Deficiencies (3)
F 0677: The facility did not provide ordered adaptive equipment such as divided plates and double-handled spout cups to residents during meals, impairing their ability to eat independently.
F 0804: Food was served at unsafe temperatures, including milk at 63-64°F and overcooked, burned ravioli, violating food service safety standards.
F 0812: The main kitchen was not maintained in accordance with professional standards; floors, ice machine, and walk-in freezer were unclean, hand wash signage was missing, and expired milk was stored in the cooler.
Report Facts
Residents affected: 2
Milk cartons measured: 50
Milk crates dated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #17 | Stated certified nurse aides were to check meal trays for accuracy including adaptive equipment. | |
| Certified Nurse Aide #6 | Verified meal trays included adaptive equipment and would call kitchen if incorrect. | |
| Certified Occupational Therapy Assistant #19 | Explained importance of divided plates for residents with impaired vision. | |
| Director of Rehabilitation | Stated importance of ordered divided plates for resident independence. | |
| Licensed Practical Nurse #7 | Oversaw tray pass and meals, emphasized importance of correct adaptive equipment. | |
| Licensed Practical Nurse Unit Manager #3 | Expected staff to check meal tickets against tray contents for accuracy. | |
| Food Service Director #32 | Acknowledged lack of formal training and issues with food temperature and kitchen cleanliness. | |
| Cook #33 | Stated they did not serve hard or burned food but acknowledged ravioli could have been overcooked. | |
| Kitchen Manager #32 | Reported milk not discarded on expiration date and kitchen cleaning responsibilities. | |
| Administrator | Reported staffing issues related to COVID-19 impacting kitchen efficiency. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 21
Date: Dec 15, 2023
Visit Reason
Inspection found multiple Level 2 deficiencies in standard health and life safety code categories, mostly isolated or pattern scope, with corrections completed by February 2024.
Findings
Inspection found multiple Level 2 deficiencies in standard health and life safety code categories, mostly isolated or pattern scope, with corrections completed by February 2024.
Deficiencies (21)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Dialysis
Food procurement,store/prepare/serve-sanitary
Increase/prevent decrease in rom/mobility
Infection prevention & control
Nutritive value/appear, palatable/prefer temp
Qualified dietary staff
Respiratory/tracheostomy care and suctioning
Cooking facilities
Corridor - doors
Discharge from exits
Fire alarm system - installation
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Illumination of means of egress
Means of egress - general
Number of exits - corridors
Portable fire extinguishers
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Jul 2, 2021
Visit Reason
The survey was a recertification and abbreviated survey conducted from 6/29/21 to 7/2/21 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident rights, activities of daily living, nutrition and hydration, medication administration, infection control, staffing, and food service. Specific issues included delayed meal service, inadequate assistance with ADLs, significant unaddressed weight loss, medication errors, improper infection control practices, insufficient staffing, and food not served at proper temperatures or consistent with dietary orders.
Deficiencies (12)
F550: The facility did not ensure residents #71 and #72 were served meals in a dignified manner and were served after other residents.
F0677: The facility failed to provide necessary assistance with activities of daily living for residents #2, 18, 22, 36, and 54, including missed showers, grooming, toileting, and dressing.
F0689: Resident #101 sustained multiple falls and the care plan was not updated with interventions to prevent further falls.
F0692: Residents #22 and #99 had significant weight loss and were not reweighed to verify and address the loss appropriately.
F0695: Resident #50 had orders for CPAP and BiPAP therapy but no treatment administration or cleaning instructions were documented and care plan was not updated accordingly.
F0725: The facility failed to ensure sufficient nursing staff to meet resident needs, resulting in delayed medications, missed showers, inadequate assistance, and unmet resident rights.
F0759: Resident #72 was administered Basaglar insulin without a physician order and Resident #20 received three medications over one hour late; medication error rate was 7.55%.
F0761: Expired medications were found in Unit 2 medication cart L and medication room; monthly expiration checks were not documented.
F0804: Food was not served at palatable temperatures for 2 lunch meals; examples included cold French fries, lukewarm roast beef sandwich, and pudding served at 71°F.
F0805: Resident #61 on a pureed diet received soft cookies not approved by speech pathology; Resident #20 on a pureed diet received pudding pie with graham cracker crust, which is not compliant with diet orders.
F0806: Residents #4, 18, 31, 33, 39, 50, 54, 82, 96 and 3 anonymous residents did not receive food items or condiments as specified on their meal tickets, including missing ketchup, mayonnaise, and incorrect desserts.
F0880: LPN #18 used improper infection control practices including uncapping insulin needles with teeth, not performing hand hygiene between residents, and improper mask use. TNA #12 failed to wear required PPE when repositioning Resident #252 on droplet/contact precautions. LPN #11 did not wear gloves during tube feeding administration for Resident #20.
Report Facts
Medication error rate: 7.55
Resident census: 108
Weight loss: 37.2
Weight loss: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Administered Basaglar insulin without order, administered medications late, and observed with poor infection control practices. |
| LPN #18 | Licensed Practical Nurse | Observed using improper infection control practices including uncapping needle with teeth and not performing hand hygiene. |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Provided statements on medication errors, care plan updates, infection control expectations, and staffing. |
| DON | Director of Nursing | Provided statements on medication errors, care plan updates, infection control, and staffing. |
| ADON | Assistant Director of Nursing | Provided statements on care plan responsibilities, infection control, and staff expectations. |
| RD #32 | Registered Dietitian | Provided statements on weight monitoring and nutritional interventions. |
| CNA #24 | Certified Nurse Aide | Reported staffing shortages and meal tray inconsistencies. |
| Food Service Director | Provided statements on food temperature standards and meal tray substitutions. | |
| TNA #12 | Temporary Nurse Aide | Observed not wearing required PPE and provided statements on PPE use. |
| SLP #31 | Speech Language Pathologist | Provided statements on diet consistency and food safety. |
Viewing
Loading inspection reports...
