Safire Rehabilitation of Northtowns, L L C

Inspectors wroteBased on observation, record review, and interview during survey, the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents/hazards for two (Resident #1 and Resident #2) of five residents reviewed for accidents. a.) Specifically, on 06/04/2026 Resident #1 who was severely cognitively impaired, wore a wander alert device due to being at high risk for elopement, exited the facility undetected through doors that were not secured by the wander alert system. Resident #1 was located 12 hours later approximately three miles away by local police. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #1's health and safety. b.) On 06/29/2026, Resident #2's wander alert device failed to alarm when tested.

Inspectors wroteBased on interview and record review during survey, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure a safe environment for cognitively impaired residents who wander and/or are at risk for elopement. a.) Specifically, Resident #1 was located 12 hours later approximately three miles away by local police on 06/04/2026. b.) On 06/29/2026, Resident #2's wander alert device failed to alarm when tested and the facility had no policy, current manufacturers guidance or system that monitored the functionality of the wander alert bracelets weekly per the manufacturers' recommendations. [...]

Inspectors wroteBased on observation, interview and record review conducted during the survey, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse and do not result in serious bodily injury, to the State Survey Agency for one (1) (Resident #4) of three (3) residents reviewed. Specifically, the Administrator was notified of an injury of unknown origin to Resident #4's left hand and it was not reported to the State Agency as required. [...]

Inspectors wroteBased on observation, interviews and record review conducted during a survey, the facility did not ensure that menus were followed and prepared to meet resident choices and nutritional needs in accordance with established national guidelines for one (1) of one (1) kitchen. Specifically, on 02/25/2026 the kitchen did not prepare an adequate amount of the posted lunch meal to serve all residents. Additionally, during meal observation residents did not receive food/beverage items that were listed on their meal tickets. This involved Residents #2, #5, #6, and #7.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 3/28/25 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one main Kitchen and three (Unit 1, Unit 2, and Unit 3) of three Nourishment Kitchens. Specifically, the main Kitchen had issues with opened undated, outdated, and/ or unlabeled foods. The floors throughout the Kitchen and dry storage room had copious amounts of debris under the equipment, storage racks, and the floors had areas of dark black buildup. The equipment was dirty and sticky. The steam table was being held up by a canned good in one corner. Hoods and pipes along the ceiling had a thick layer of dust and grease buildup. Paint on the ceiling was peeling in areas and the ceiling had a buildup of multiple dark dirty spots. [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00348183, #NY00338640) during a Standard survey completed on 3/28/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not have sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs 15 out of 30 days and falling below the State average daily staffing hours per resident per day. The finding is: Refer to F 658 Refer to F 677 Refer to F 561 The policy and procedure titled Nursing Department Staffing dated 2/17/2021 documented the facility provides adequate staffing to meet needed care and services for their resident population. [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 3/28/25, the facility did not ensure a Quality Assurance and Performance Improvement program (QAPI) developed, implemented, monitored, maintained effective systems, and used feedback to develop an appropriate plan of action to correct identified deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance, and there were repeated deficiencies from the previous Standard survey 9/18/23 and Compliant survey 2/22/24 in Food and Nutritional Services. In addition, there were patterned and wide spread cited deficiencies.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00347069) during a Standard survey completed on 3/28/25, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one of one facility reviewed for infection control. Specifically, staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) during morning care, urinary catheter (foley-a tube inserted into the bladder to drain urine) care, and wound care and staff did not remove their gloves or wash hands after incontinent care was provided and before touching clean items for Resident #19; [...]

Inspectors wroteBased on interview, observation, and record review conducted during complaint investigations (NY00348183, NY00338640, NY00335062, NY00347069) conducted during a Standard survey completed on 3/28/2025, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (3) (Units 1, 2, and 3) of three (3) resident units. Specifically there were issues with dirty floors (Units 1, 2, 3); dirty window curtains in disrepair (Units 2, 3); stained privacy curtains in disrepair (Units 1, 2, 3); window blinds with missing or broken slats (Units 1, 2, 3); walls had chipped paint and spackled areas that were not sanded or painted (Units 1, 2, 3); dirty wall register covers (Units 1, 2, 3); resident's bed had missing molding around the footboard (Unit 3); soiled fall mats (Unit 2): [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (1) (Resident #48) of one (1) reviewed. Specifically, Resident #48 was treated by nursing staff members in an undignified and demeaning manner. The issues involved staff grabbing and yanking the residents clothing to keep them seated; lack of staff intervention when the resident experienced agitation in a common area; transporting the resident facing backwards through the hall; inappropriate use of a staff members foot against the residents face to support their head after a fall; [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Standard survey completed on 3/28/25, the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for two (2) (Resident #53 and #90) of five (5) residents reviewed for choices. Specifically, Resident #53 missed two scheduled orthopedic consult appointments and Resident #90 was not provided with showers twice a week per their preference.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00365639) during a Standard survey completed on 3/28/25, the facility did not ensure the resident's right to be free from physical restraints imposed for the purposes of discipline or convenience and is not required to treat the residents' medical symptoms for one (Resident #48) of four residents reviewed. Specifically, Resident #48 was physically restrained by a staff member in bed. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents with a revised date of 2/2023 documented acts of abuse against residents were absolutely prohibited. Abuse includes control of resident's behavior through corporal punishment. Unlawful restraint is intentionally or knowingly using physical or chemical restraints or medication on a care-dependent person. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Standard Survey completed on 3/28/25, the facility did not provide services consistent with professional standards of quality for one (Resident #444) of 25 residents reviewed. Specifically, Resident #444 did not receive an intravenous medication as ordered by the physician and the physician was not notified of those omissions. The policy and procedure titled administering medication/treatments dated 12/1/17, documented medications shall be administered in a safe and timely manner and as prescribed including any required time frame and state regulations. If the drug is withheld or refused, the licensed nurse administering the medication will document accordingly in the electronic medical record and notify the nursing supervisor. 1. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00335062, NY00338640, and NY00347069) during the Standard survey completed on 3/28/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (Resident #82, #19 and #79) of six residents reviewed. Specifically, Resident #82 had long fingernails with brown debris underneath them on multiple observations; Resident #19 had facial hair that they wanted removed and during morning care observation staff did not offer shaving; [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (1) (Resident #19) of three (3) residents reviewed. Specifically, staff did not follow physician orders when completing a pressure ulcer treatment. In addition, there was a delay in assessments and notification to the physician regarding a declining skin concern and newly identified pressure ulcer. The finding is: The policy and procedure titled Skin and Wound Care Policy dated 5/10/18 documented, the purpose is to facility the prevention and or treatment of impaired skin integrity, by assessing and planning care immediately upon identification of residents at risk or with existing wounds. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #48) of five (5) reviewed for accidents. Specifically, staff did not remove Resident #48 from the common area/dining room to a lesser stimulating environment as care planned when they had increased agitation and the resident fell out of their Geri chair (specialized chair designed for elderly or disabled individuals), hitting their head on the floor; staff inappropriately transferred the resident from the floor back into their chair and the resident landed on their face. Additionally, care plan interventions were not revised after the resident fell on 3/24/25. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 3/28/25, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for two (Resident #13 and #19) of three residents reviewed. Specifically, infection control practices were not maintained when caring for residents with an indwelling foley catheter. Resident #13's foley catheter drainage bag (used to collect urine) was observed on the floor and Resident #19's foley catheter drainage bag was improperly emptied. Additionally, the comprehensive care plan was not developed to include the use of an indwelling foley catheter and the Minimum Data Set ( a resident assessment tool) was coded inaccurately (#13).

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that the pharmacist reported irregularities to the attending physician and the facility's Medical Director, and the Director of Nursing, and that these reports were acted upon for two (Residents #25 and #75) of five residents reviewed for drug regimen reviews. Specifically, the Consultant Pharmacist did not report a gradual dose reduction for a psychotropic medication had not been attempted at least annually per the facility protocols (#25). In addition, the Consultant Pharmacist recommendations on 10/17/24 and 12/5/24 were not acted upon (#75).

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey, completed on 3/28/25, the facility did not provide or obtain dental services to meet the resident's needs for one (Resident #74) of one resident reviewed. Specifically, there was a lack of timely follow - up on dental recommendations for extractions (removal of teeth). The finding is: The policy titled Dental Services, last revised 1/26/2020, documented routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The Director of Nursing or their designee was responsible for notifying social services of a resident's need for dental services and coordinating appointments with Medical Records/ Unit Clerks. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 3/28/25, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, were not reviewed through the New York State Nurse Aide Registry prior to their employment as required. This affected three (Employee #1, Activities Aide, Employee #8, Dietary Aide, and Employee #9, Dietary Aide) of seven employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, that were not reviewed through the New York State Nurse Aide Registry prior to their employment as required.

Inspectors wroteBased on observation, interviews, and record review conducted during the Onsite Post Survey Revisit #1, the facility did not ensure all menus were followed for four (Residents #1, 2, 3 and 4) of 7 residents reviewed. Specifically, residents were not served a ground consistency diet as planned. This is a continuing deficiency from the abbreviated survey completed 11/12/2024.

Inspectors wroteBased on observation, interview, and record review during the Abbreviated survey (complaint # NY00329948) completed on 2/15/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one kitchen had issues that included undated and outdated food, a cooked food item stored adjacent to raw meat, flies observed, no single service towels at the handwash sink, multiple soiled surfaces, missing wall tiles, and missing floor tiles.

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 9/18/23, it was determined that the facility did not ensure maintenance of an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for one of one facility water management systems. Specifically, water samples that tested positive for Legionella was not reported to the New York State Department of Health (NYS DOH) and institute short-term control measures when control measures were not met. Additionally, staff that administered the facility's Potable Water Sampling and Management Plan did not notify the facility Infection Preventionist of the positive Legionella water sample results.

Inspectors wroteBased on interview and record review conducted during a Standard survey completed 9/18/23, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services. The finding is: Refer to F 804, F 809, and F 812 The undated policy and procedure (P&P) titled Food and Nutrition Services documented it is the policy of the facility to ensure that facility staff supports the nutritional wellbeing of the residents while respecting an individual's right to make choices about his or her diet. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 9/18/23, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for four (1st, 2nd, 3rd, and 4th floors) of four test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #1, #5, #19, #34, #40, #55, #57, #77, #341, and #388 were involved.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 9/18/23 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: [...]

Inspectors wroteBased on observation, record review, and interviews during the Standard Survey completed on 9/18/23, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Residents #26) of 3 residents reviewed for resident choices. Specifically, residents were not provided a choice to take a tub bath because there was no working bathtub in the facility. The finding is: The policy and procedure (P&P) titled Quality of Life - Self Determination and Participation dated 9/1/17 documented the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00294631) during a Standard survey completed on 9/18/23, the facility did not ensure that the resident's representative was notified immediately of a change of condition for one of three residents (Resident #12) reviewed for notification of change. Specifically, Resident #12's representative was not notified of the resident's tooth pain, loose tooth, and the loss of the tooth that required treatment. The finding is: 1. Resident #12 was admitted to the facility with diagnosis of dementia and high blood pressure. The Minimum Data Set (MDS - a resident assessment tool) dated 8/18/23 documented Resident #12 was moderately cognitively impaired, understood by others, and understands others. The MDS documented that the resident did not have any oral or mouth issues. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 9/18/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (Resident #5) of one resident reviewed for activities. Specifically, Resident #5 was not provided accommodations for activities for an individual who was visually impaired. [...]

Inspectors wroteBased on observation, interview and record review conducted on a Standard survey completed 9/18/23, the facility did not ensure each resident be provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for three (Unit 1, Unit 2, and Unit 3) of three units. Specifically, resident meal trays were served up to 60 minutes after scheduled mealtimes. Residents' #1, 59, 61 and 75 were involved.

Inspectors wroteBased on interview and record review during the Standard survey completed on 11/19/21, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees A, B, C, and F) of seven employees that worked in the facility and were subject to the New York State Nurse Aide Registry, had been screened through the New York State Nurse Aide Registry prior to their employment.

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 11/19/21, the facility did not maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. Specifically, a shower plumbing device and hose did not have a vacuum breaker installed to prevent backflow. Also plumbing pipes were open and uncapped. This affected three (Basement, First and Second floors) of four resident use floors.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed 11/19/21, the facility did not ensure that grievances were filed on behalf of residents and thoroughly investigated. Specifically, residents voiced complaints of missing personal belongings, the facility did not file grievances on behalf of the residents and did not complete investigations into the missing personal belongings. This involves Residents #5, 18, 40, 47, 66.

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (NY00282505) during the Standard survey completed on 11/19/2021, the facility did not ensure all alleged violations involving injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. Specifically, two (Residents #20, 33) of five residents reviewed for abuse bruising of unknown origin was not reported to the New York State Department of Health (NYSDOH) as required.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard Survey (Complaint# NY00272002 & NY00272117) completed on 11/19/21, the facility did not have the evidence that all alleged violations of abuse were thoroughly investigated for three (Resident #9, 33, 68) of five residents reviewed. Specifically, there was a lack of thorough investigations into injuries of unknown origin (#33, 68) and resident self-reported alleged abuse (#9).

Inspectors wroteBased on interview and record review conducted during the Standard survey completed 11/19/21, the facility did not ensure that residents who require dialysis received services consistent with professional standards of practice for one (Resident #56) of one resident reviewed. Specifically, the resident's left arm Arteriovenous (AV) fistula (a tube or device surgically implanted to create an artificial connection between an artery and a vein) access site was not monitored for patency by checking for bruit (a rumbling or whooshing sound you can hear) and thrill (a rumbling or buzzing sensation that you can feel) per physician's order. The finding is: The facility policy and procedure titled Dialysis dated 1/19/2019 documented the facility had established standards of care for the dialysis resident. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 11/19/21, the facility did not provide food prepared in a form designed to meet individual needs for one of 3 residents (Resident #35) reviewed for food. Specifically, the facility did not ensure proper ground consistency was provided. The finding is: The facility policy and procedure (P&P) titled Therapeutic Diets with a revision date of 11/1/21 documented therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his/her goals and preferences. If a mechanically altered diet (requires change in texture of food or liquids) is ordered, the provider will specify the texture modification of ground, chopped or puree. 1. [...]