Safire Rehabilitation of Northtowns, LLC

Safire Rehabilitation of Northtowns, LLC

2799 Sheridan Drive

Tonawanda , NY 14150

7168374466

Services: Baseline Services

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:100
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:100

Administrative

Ownership: Proprietary--LLC

Operated by: Safire Rehabilitation of Northtowns, LLC
2799 Sheridan Drive
Tonawanda, NY 14150

Permanent Facility Identifier: 266

Operating Certificate: 1403304N

Medicaid Certified

Medicare Certified

Medicare Number: 335180

Statistics

Employee Flu Vaccination Rate: 45%

Occupancy Rate: 87%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain0.00009/1/2018
425Percentage of short-stay residents with pressure ulcers that are new or worsened2.24009/1/2018
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine72.16009/1/2018
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine66.34009/1/2018
434Percentage of short-stay residents who newly received an antipsychotic medication1.15009/1/2018
471Percentage of short-stay residents who made improvements in function73.30009/1/2018

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased23.37009/1/2018
402Percentage of long-stay residents who self-report moderate to severe pain0.00009/1/2018
403Percentage of high risk long-stay residents with pressure ulcers11.16009/1/2018
404Percentage of long-stay residents who lose too much weight9.51009/1/2018
405Percentage of low risk long-stay residents who lose control of their bowels or bladder40.31009/1/2018
406Percentage of long-stay residents with a catheter inserted and left in their bladder2.05009/1/2018
407Percentage of long-stay residents with a urinary tract infection4.41009/1/2018
408Percentage of long-stay residents who have depressive symptoms4.32009/1/2018
409Percentage of long-stay residents who were physically restrained0.00009/1/2018
410Percentage of long-stay residents experiencing one or more falls with major injury4.35009/1/2018
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine93.41009/1/2018
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine85.62009/1/2018
419Percentage of long-stay residents who received an antipsychotic medication16.10009/1/2018
451Percentage of long-stay residents whose ability to move independently worsened22.73009/1/2018
452Percentage of long-stay residents who received an antianxiety or hypnotic medication15.55009/1/2018

Complaints

Number of Standard Health Deficiencies:67
Number of Live Safety Code Deficiencies:27
Number of Total Deficiencies:94
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:2
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :2
Total intakes received (last three years):138
Intakes received per 100 occupied beds (last three years):151.2
Percent of total intakes received that were facility self reported incidents (last three years):46
On-site complaint investigations (last three years):42
Complaint investigations resulting in citations (last three years):14
Complaint investigations resulting in citations per 100 occupied beds (last three years):15.3
Complaint Citations in deficiency category: Administration:3
Complaint Citations in deficiency category: Quality of Care:8
Complaint Citations in deficiency category: Resident Rights:2
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:0
Complaint Citations in deficiency category: Other Services:1
Complaint Citations across all deficiency categories (last three years):14

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
Quality of Care2/24/20056000
5/14/2003Quality of Care3/1/20054000
9/15/2016Quality of Care12/19/201612000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
10/2/2015Certification2
12/14/2016Certification2
3/16/2018Certification2
3/26/2015Complaint2
5/19/2016Complaint2
7/6/2017Complaint2
9/15/2016Complaint2
9/26/2017Complaint2
9/29/2014Certification2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthBEDROOMS ASSURE FULL VISUAL PRIVACY1110/2/2015
HealthCare Plan Timing and Revision113/16/2018
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS219/29/201411/17/2014
HealthRESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE129/29/201411/17/2014
HealthNUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP129/29/201411/17/2014
HealthRIGHT TO TELEPHONE ACCESS WITH PRIVACY129/29/201411/17/2014
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES219/29/201411/17/2014
HealthDIGNITY AND RESPECT OF INDIVIDUALITY219/29/201411/17/2014
HealthHOUSEKEEPING & MAINTENANCE SERVICES229/29/201411/17/2014
HealthSERVICES BY QUALIFIED PERSONS/PER CARE PLAN219/29/201411/17/2014
LSCLIFE SAFETY CODE STANDARD239/29/201411/17/2014
LSCLIFE SAFETY CODE STANDARD229/29/201411/17/2014
LSCLIFE SAFETY CODE STANDARD229/29/201411/17/2014
LSCLIFE SAFETY CODE STANDARD229/29/201411/17/2014
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE219/26/201711/3/2017
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING319/15/201611/9/2016
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS319/15/201611/9/2016
HealthDRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON219/15/201611/9/2016
HealthSUFFICIENT 24-HR NURSING STAFF PER CARE PLANS2210/2/201512/1/2015
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS2110/2/201512/1/2015
HealthGOVERNING BODY-FACILITY POLICIES/APPOINT ADMN2110/2/201512/1/2015
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS2110/2/201512/1/2015
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS2210/2/201512/1/2015
LSCLIFE SAFETY CODE STANDARD2310/2/201512/1/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2110/2/201512/1/2015
LSCLIFE SAFETY CODE STANDARD2210/2/201512/1/2015
LSCLIFE SAFETY CODE STANDARD2210/2/201512/1/2015
LSCLIFE SAFETY CODE STANDARD2210/2/201512/1/2015
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES2210/2/201512/1/2015
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2110/2/201512/1/2015
HealthDIGNITY AND RESPECT OF INDIVIDUALITY2110/2/201512/1/2015
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES2110/2/201512/1/2015
HealthHOUSEKEEPING & MAINTENANCE SERVICES2210/2/201512/1/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS2110/2/201512/1/2015
HealthSERVICES BY QUALIFIED PERSONS/PER CARE PLAN2110/2/201512/1/2015
HealthPASRR REQUIREMENTS FOR MI & MR2110/2/201512/1/2015
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE2110/2/201512/1/2015
LSCLIFE SAFETY CODE STANDARD2210/2/201512/1/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2110/2/201512/1/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2110/2/201512/1/2015
HealthINCREASE/PREVENT DECREASE IN RANGE OF MOTION2110/2/201512/1/2015
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE2110/2/201512/1/2015
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS2112/14/20162/12/2017
HealthMENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWED2212/14/20162/12/2017
HealthROUTINE/EMERGENCY DENTAL SERVICES IN NFS2112/14/20162/12/2017
LSCVertical Openings - Enclosure2212/14/20162/12/2017
LSCFire Alarm System - Testing and Maintenance2212/14/20162/12/2017
LSCCorridor - Doors2212/14/20162/12/2017
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING2112/14/20162/12/2017
LSCFire Drills2212/14/20162/12/2017
LSCElectrical Equipment - Power Cords and Extens2212/14/20162/12/2017
LSCElectrical Equipment - Testing and Maintenanc2212/14/20162/12/2017
HealthCriminal History Record Check Process2212/14/20162/12/2017
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)2212/14/20162/12/2017
HealthFACILITY MANAGEMENT OF PERSONAL FUNDS1212/14/20162/12/2017
LSCElevators2212/14/20162/12/2017
HealthDEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES2112/14/20162/12/2017
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE1212/14/20162/12/2017
HealthTREATMENT/DEVICES TO MAINTAIN HEARING/VISION2112/14/20162/12/2017
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES2112/14/20162/12/2017
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE2112/14/20162/12/2017
HealthRESIDENTS FREE OF SIGNIFICANT MED ERRORS2112/14/20162/12/2017
LSCBuilding Construction Type and Height2212/14/20162/17/2017
HealthADL Care Provided for Dependent Residents213/16/20185/14/2018
HealthTreatment/Svcs to Prevent/Heal Pressure Ulcer213/16/20185/14/2018
HealthFree from Unnec Psychotropic Meds/PRN Use213/16/20185/14/2018
HealthReporting of Alleged Violations223/16/20185/14/2018
HealthInvestigate/Prevent/Correct Alleged Violation223/16/20185/14/2018
HealthBaseline Care Plan213/16/20185/14/2018
HealthDevelop/Implement Comprehensive Care Plan223/16/20185/14/2018
HealthFree of Accident Hazards/Supervision/Devices223/16/20185/14/2018
HealthPhysician Visits - Review Care/Notes/Order213/16/20185/14/2018
HealthPharmacy Srvcs/Procedures/Pharmacist/Records223/16/20185/14/2018
HealthLabel/Store Drugs and Biologicals213/16/20185/14/2018
HealthAdministration223/16/20185/14/2018
HealthResident Records - Identifiable Information213/16/20185/14/2018
HealthDEVELOP COMPREHENSIVE CARE PLANS213/26/20155/22/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING213/26/20155/22/2015
HealthNot Employ/Engage Staff w/ Adverse Actions223/16/20185/7/2018
HealthInfection Control223/16/20185/7/2018
HealthCriminal History Record Check Process223/16/20185/7/2018
HealthDepartment Criminal History Review223/16/20185/7/2018
LSCSubsistence Needs for Staff and Patients133/16/20185/7/2018
HealthResident Rights/Exercise of Rights123/16/20185/7/2018
LSCRoles Under a Waiver Declared by Secretary133/16/20185/7/2018
LSCPrimary/Alternate Means for Communication133/16/20185/7/2018
LSCLTC and ICF/IID Sharing Plan with Patients133/16/20185/7/2018
HealthInfection Prevention & Control223/16/20185/7/2018
LSCCooking Facilities213/16/20185/7/2018
LSCSprinkler System - Maintenance and Testing223/16/20185/7/2018
LSCFire Drills223/16/20185/7/2018
LSCFundamentals - Building System Categories223/16/20185/7/2018
LSCElectrical Systems - Essential Electric Syste223/16/20185/7/2018
LSCElectrical Equipment - Testing and Maintenanc223/16/20185/7/2018
LSCBuilding Construction Type and Height223/16/20186/11/2018
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE215/19/20166/2/2016
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES217/6/20178/10/2017