Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Safire Rehabilitation Of Northtowns, L L C during CMS and state inspections, most recent first.
Two residents were involved in a deficiency related to supervision and wander alert safety. One resident with severe cognitive impairment and known elopement risk exited the facility unnoticed through unsecured doors and was found miles away by police. A second resident’s wander alert bracelet failed to alarm during an elevator transfer, and staff later found the bracelet battery was dead. Leadership and nursing staff stated there was no policy for door checks or for the current wander alert system.
A facility failed to maintain effective wandering and elopement safeguards for cognitively impaired residents. One resident with Alzheimer’s disease and severe cognitive impairment exited through an unsecured maglock door and was found by police hours later, while another resident’s wander alert bracelet failed to alarm when tested. Staff, including the DON, ADM, and DOR, reported there was no policy or documented process for testing the current wander alert system or monitoring bracelet function, and the facility had no system for checking the maglock doors before the incident.
The facility failed to timely report an injury of unknown origin involving a cognitively impaired, combative resident with dementia, stroke history, and aphasia. During morning care, a CNA discovered the resident’s left hand to be swollen, bruised, and difficult to move, and notified an LPN, who informed the nurse manager. An x‑ray later confirmed a fracture of the second proximal phalanx. Nursing leadership treated the event as an injury of unknown origin and understood that such incidents must be reported to the Department of Health within two hours, with the Administrator responsible for reporting. However, the Administrator did not submit the required report because they believed no abuse, neglect, or mistreatment had occurred, resulting in noncompliance with abuse and injury reporting regulations.
Surveyors found that the facility failed to follow posted menus and provide sufficient quantities of planned meals, resulting in residents not receiving the listed entrées, beverages, and condiments on their meal tickets. Multiple residents and staff reported frequent complaints about food being cold, unappealing, missing items, and not matching tickets, with condiments and juices often unavailable. During an observed meal service, the kitchen ran out of the main entrée and the designated alternate, leading to unplanned substitutions such as plain breaded chicken patties on rolls without condiments. Staff acknowledged not using production sheets correctly, failing to count portions, and experiencing stockouts of items like juice, jelly, sugar, and specific cheeses, while also citing ordering and delivery problems that contributed to the deficiencies.
The facility failed to provide meals in the required ground consistency for residents with dysphagia and other conditions, as observed during a survey revisit. Despite dietary cards and care plans indicating the need for ground diets, meals were served incorrectly, with staff sometimes improvising by cutting food into smaller pieces. The Director of Food Services and the DON acknowledged the importance of serving meals in the correct form to meet residents' needs.
Failure to Prevent Elopement and Ensure Wander Alert Device Functionality
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for two residents. One resident had diagnoses including Alzheimer’s disease, alcohol abuse, and COPD, and was assessed as having severe cognitive impairment. The resident was identified on admission as having wandering, exit-seeking, and elopement risk, and the baseline care plan noted the resident wore a wander alert bracelet on the right wrist. On the morning of the incident, the resident was not found in the room during breakfast service, and staff initiated a search and notified leadership, the spouse, and law enforcement. The resident was later found by police approximately three miles from the facility and returned that evening. Video surveillance showed the resident walking alone through the third-floor west wing, past the nurses’ station, toward an emergency exit door, then continuing down the east wing hallway toward a stairwell door that led to the first-floor exit to the parking lot. The surveillance outside the building showed a laundry aide arriving and remaining in a vehicle while the resident exited the facility. The report also states that the stairwell door had a keypad and magnetic locking system, but the first-floor exit door near the parking lot had no alarm system, and the wander alert system did not cover the doors the resident used to leave the building. During interviews, maintenance staff stated that magnets on the magnetic-locked doors had previously slipped and disengaged the locking mechanisms, and the administrator stated the facility did not have a policy regarding door checks. A second resident had diagnoses including hypertension, diabetes mellitus, and depression. The resident was listed on the facility’s wander alert list as a wanderer, but the resident’s assessment documented independence with transfers and wheelchair mobility and no wandering behaviors. During observation, a unit clerk wheeled the resident to the elevator, and the wander alert device did not alarm when the resident entered the elevator. When the assistant director of nursing replaced the bracelet with a new one and tested it, the system sounded. The assistant director of nursing stated the old bracelet’s battery was no good and did not know how long it had been dead. Staff and leadership stated they did not have a policy for the current wander alert system, and the director of nursing stated routine checks had been stopped when the new system was implemented.
Unsafe wandering and elopement safeguards were not effectively managed
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of residents because it failed to ensure a safe environment for cognitively impaired residents who wander or are at risk for elopement. The report identified two separate events involving wandering safety systems and noted that the deficiency affected seven residents identified as at risk for unsafe wandering and elopement. Resident #1 had diagnoses including Alzheimer's disease, alcohol abuse, and COPD, and the Minimum Data Set dated 06/08/2026 assessed the resident as having severe cognitive impairment. On 06/04/2026, the resident was located by local police approximately 12 hours later and about three miles away. Staff interviews indicated that the resident exited through a door associated with the third-floor east stairwell area, and the Maintenance Assistant stated the maglock may have slipped and disengaged, causing the door to inactivate and the alarm not to sound. The Director of Maintenance stated the third-floor east wing stairwell door used a keypad and magnetic locking system, that the first-floor exit door near the parking lot had no alarm system, and that the facility had no system for checking the doors prior to the incident. Resident #2 had diagnoses including hypertension, diabetes mellitus, and depression. The Minimum Data Set documented the resident as independent with chair/bed-to-chair transfers and wheelchair mobility and as having no wandering behaviors. During testing on 06/29/2026, the resident's wander alert device failed to alarm. Staff interviews further revealed there was no documented policy for testing the wander alert system or resident bracelets, and the facility had no current system for monitoring bracelet functionality weekly per manufacturer recommendations. The Director of Maintenance stated they could not find a policy for the wander alert system and only obtained manufacturer guidance after contacting the manufacturer, while the Administrator stated they assumed the system monitored bracelet functionality.
Failure to Timely Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin for Resident #4 to the State Survey Agency within the required timeframe. Facility policy and federal regulation require that all alleged violations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source be reported immediately, but not later than two hours if abuse or serious bodily injury is involved, or within 24 hours if not. Despite this, when Resident #4 was found with a swollen, bruised left index finger that was later confirmed by x‑ray to be an oblique fracture of the second proximal phalanx, the Administrator did not report the incident to the Department of Health because they did not believe abuse, mistreatment, or neglect had occurred. Resident #4 had significant cognitive and behavioral issues, including vascular dementia with mood disturbances, a history of stroke, aphasia, severe cognitive impairment, confusion, agitation, and combative behaviors with care such as hitting and grabbing staff. Care plans and resident care profiles documented noncompliance, rejection of care, poor safety awareness, and resistance to activities of daily living, with interventions focused on behavior modification and de‑escalation. On the morning of 10/14/2025, a CNA discovered swelling and bruising of Resident #4’s left index finger and knuckles during morning care and immediately reported it to an LPN, who then reported it to the RN Manager. Staff interviews confirmed that Resident #4 was known to be combative during care and that no prior concerns about the hand had been noted the previous night. The injury was treated as an injury of unknown origin by nursing leadership, who completed an incident report, notified the medical provider and family, and initiated an internal review by collecting staff statements going back 72 hours. The ADON and DON both stated that injuries of unknown origin are supposed to be reported to the Department of Health within a two‑hour window and that the Administrator is responsible for making such reports. The Administrator acknowledged that injuries of unknown origin, abuse, mistreatment, and neglect are to be reported within two hours of notification but chose not to report Resident #4’s injury because they believed no abuse had occurred and later stated that, in retrospect, they should have reported it as required by regulation.
Failure to Follow Menus and Provide Required Food Items and Condiments
Penalty
Summary
The deficiency involves the facility’s failure to follow posted menus and provide meals that met residents’ nutritional needs and stated preferences, as required by facility policy and national guidelines. The facility’s Food and Nutrition Services policy required that each resident receive a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, with reasonable efforts to accommodate preferences, and that food trays be inspected to ensure the correct meal is provided. The Tray Identification policy required appropriate identification/coding for various diets and special considerations. The posted Fall/Winter Week 1 menu for the identified lunch specified stuffed shells (two each), Italian vegetables, a dinner roll, and pie, with an egg salad sandwich as the alternate, yet the kitchen did not prepare an adequate amount of the posted lunch meal to serve all residents. Surveyors identified ongoing concerns from Resident Council notes and staff and resident interviews about food quality, availability, and accuracy. Resident Council notes from two consecutive months documented that food was out of stock, supplies were low, items were missing, and there were complaints about food quality (such as steak being hard to cut). Multiple residents reported not receiving condiments, receiving small portions, and being served cold and unappealing food. Nursing staff and CNAs corroborated that there were many resident complaints about food being inedible, cold, unappealing, and poorly presented, with food “slopped” on trays, condiments rarely provided despite being listed on meal tickets, and no use of bases under plates to keep food warm. Staff also reported that residents’ meal tickets often did not match what was provided on trays due to menu changes or lack of supplies, and that condiments and juices were not readily available on the units. Direct meal observations and interviews on specific survey dates showed that residents did not receive items listed on their meal tickets and that the kitchen ran out of the main entrée. For breakfast, one resident’s meal ticket indicated jelly and apple juice, but their tray lacked both items, which the resident stated they would have liked. Another resident’s ticket indicated orange juice and jelly, but their tray lacked orange juice, jelly, and sugar; the resident’s oatmeal remained uneaten, and an LPN reported being told by kitchen staff that there was no jelly or juice available. Another resident reported not receiving stuffed shells with red sauce, orange juice, or sugar as expected and stated they minded. A further resident stated they hardly ever received what was on their meal ticket, were frequently told items had run out and were substituted, and reported that juices such as orange, cranberry, and apple juice were never provided, with powdered fruit punch being used instead. During the observed lunch tray line, kitchen staff discussed that there were not enough stuffed shells and meat sauce to complete all resident trays, and the Dietary Supervisor acknowledged that not enough food had been pulled out. The kitchen ran out of stuffed shells before completing all carts, and the Clinical Dietician/Food Service Director stated that approximately twenty residents were unable to receive stuffed shells as posted on the menu. The alternate egg salad sandwich was also insufficient in quantity, leading staff to prepare breaded chicken patties on rolls without condiments or sauce as additional substitutions. Insulated plate bases were used as lids but did not fully cover plates. Dietary supervisors and the Food Service Director acknowledged that production sheets, which indicate required amounts and portions, were not properly used or understood, that counts of stuffed shells were not done, and that supplies such as orange juice, sugar packets, jelly packets, and Swiss cheese had run out or been used previously. The Administrator later stated that Food Service Directors should have recognized quantity changes when ordering and confirmed that residents should receive what is on the menu and all items listed on their meal tickets, and also noted issues with deliveries, wrong items, and misdirected shipments that were not communicated in time to prevent stockouts.
Failure to Provide Ground Consistency Diets
Penalty
Summary
The facility failed to ensure that the dietary needs of residents requiring ground consistency diets were met, as observed during the Onsite Post Survey Revisit #1. Specifically, four residents were not served meals in the required ground consistency, despite their dietary cards and care plans indicating the need for such modifications due to conditions like dysphagia and cognitive impairments. This deficiency was noted as a continuation from a previous survey. Resident #1, diagnosed with anemia in chronic kidney disease, dysphagia, and cerebrovascular disease, was observed eating a meal that did not meet the ground consistency requirement. The resident's meal included stringy beef pieces and non-ground vegetables and potatoes, contrary to the dietary card instructions. Interviews with the resident and staff revealed inconsistencies in meal preparation and supervision, with the Registered Dietician acknowledging the importance of proper food consistency to prevent choking. Similarly, Residents #2, #3, and #4, all with diagnoses necessitating ground diets, were served meals that did not adhere to their dietary requirements. Staff interviews indicated a lack of adherence to the facility's policy for checking meal trays against diet cards, with some staff improvising by cutting food into smaller pieces instead of obtaining the correct meal consistency. The Director of Food Services and the Director of Nursing both acknowledged the importance of serving meals in the correct form to meet residents' individual needs and reduce the risk of harm.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tonawanda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Amherst | 0.9 mi | ★★★★★ | 1 | 0 |
| Schofield Residence | 2.5 mi | ★★★★★ | 0 | 0 |
| Mcauley Residence | 2.8 mi | ★★★★★ | 0 | 0 |
| Rosa Coplon Jewish Home And Infirmary | 3.3 mi | — | 0 | 0 |
| Beechwood Health Care Center, Inc. | 3.5 mi | ★★★★★ | 0 | 0 |
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