Inspection Reports for
North Country Nursing & Rehabilitation Center
182 Highland Road, Massena, NY, 13662
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Inspection Report — Aug 15, 2025
Annual Inspection CMS
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.
Citations (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 — Aug 15, 2025
Complaint Investigation State
Date: Aug 15, 2025
Visit Reason
State-compiled facility profile showing 2 inspections from 2023-2025 with detailed deficiency and enforcement history.
Complaint Details
The state logged 83 complaints about this facility; 8 led to on-site inspections. Six citations resulted from those complaints.
Findings
Across two inspections in the reporting period, the facility received 62 citations, including 14 standard health and 48 Life Safety Code citations, all rated Level 2 indicating minor potential harm. The facility had 83 complaints with 8 on-site inspections and 3 enforcement actions totaling $14,000 in fines.
Citations (44)
Standard Health Citation — quality of care: Dispose Garbage And Refuse Properly.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve sanitary.
Standard Health Citation — quality of care: Menus Meet Resident Needs, prepared in advance and followed.
Standard Health Citation — quality of care: Nutrition/hydration Status Maintenance.
Standard Health Citation — quality of care: Safe/functional/sanitary/comfortable Environment.
Life Safety Code Citation — NFPA requirements: Alcohol Based Hand Rub Dispenser (ABHR).
Life Safety Code Citation — NFPA requirements: Discharge From Exits.
Life Safety Code Citation — NFPA requirements: Doors With Self-closing Devices.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extensions.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Systems.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Other.
Life Safety Code Citation — NFPA requirements: Exit Signage.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers.
Life Safety Code Citation — NFPA requirements: Smoking Regulations.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier.
Life Safety Code Citation — NFPA requirements: Subsistence Needs For Staff And Patients.
Life Safety Code Citation — NFPA requirements: Utilities - Gas And Electric.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan.
Standard Health Citation — quality of care: Dialysis.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve sanitary.
Standard Health Citation — quality of care: Increase/prevent Decrease In Range of Motion/mobility.
Standard Health Citation — quality of care: Infection Prevention & Control.
Standard Health Citation — quality of care: Nutritive Value/appearance, Palatable/preferred Temperature.
Standard Health Citation — quality of care: Qualified Dietary Staff.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning.
Life Safety Code Citation — NFPA requirements: Cooking Facilities.
Life Safety Code Citation — NFPA requirements: Corridor - Doors.
Life Safety Code Citation — NFPA requirements: Discharge From Exits.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Installation.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General.
Life Safety Code Citation — NFPA requirements: Number Of Exits - Corridors.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures.
Report Facts
Inspections on page: 2
Total violations/deficiencies cited: 62
Inspections with violations: 2
Inspections without violations: 0
Total complaints: 83
On-site complaint inspections: 8
Citations from complaints: 6
Enforcement actions: 3
Total fines: 14000
Inspection Report — Dec 15, 2023
Annual Inspection CMS
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.
Citations (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 — Jul 2, 2021
Annual Inspection CMS
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.
Citations (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
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. |
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