This document summarizes deficiencies found during a survey of the Safire Rehabilitation of Southtown nursing home. Surveyors found that the facility had not made the results of their most recent survey available for residents to view, in violation of regulations. Additionally, the facility failed to obtain stool samples as ordered by a physician for one resident, potentially harming their health. Finally, for one resident with a healing pressure ulcer, the facility did not fully implement a physician's order to apply skin protectant to the wound area, putting the resident at risk of further skin breakdown.

1. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED:2/12/2018
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
(X1) PROVIDER / SUPPLIER
/ CLIA
IDENNTIFICATION
NUMBER
335663
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
03/29/2017
NAME OF PROVIDER OF SUPPLIER
SAFIRE REHABILITATION OF SOUTHTOWN, L L C
STREET ADDRESS, CITY, STATE, ZIP
300 DORRANCE AVENUE
BUFFALO, NY 14220
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0167
Level of harm - Potential
for minimal harm
Residents Affected - Some
Allow residents to easily view the results of the nursing home's most recent survey.
Based on observation and interview conducted during the Standard survey completed on 3/29/17, the facility did not make the
results of the most recent Standard survey of the facility, conducted by Federal or State surveyors and any Plan of
Correction in effect with respect to the facility, available for examination and readily accessible to residents.
The finding is:
1. Observations of the Reception Area and the main bulletin board of the facility from 3/23/17 to 3/24/17 and on 3/27/17,
between the hours of 7:00 AM and 3:00 PM, revealed a binder entitled Survey Results. The binder contained Abbreviated
surveys from 2016. However, the binder did not contain the 5/17/16 Standard Survey results.
During an interview on 3/23/17 at approximately 2:00 PM, the Resident Council President stated I don't know where the state
inspection is posted.
During an interview on 3/24/17 at approximately 9:06 AM, the Receptionist stated that she places the documents in the Survey
Results binder, which are provided to her by the Administrator.
During an interview on 3/28/17 at approximately 9:14 AM, the Administrator stated that he thought the 5/17/16 Standard
Survey results were posted in the Survey Results binder and did not know why they were not in the binder.
415.3(c)(1)(v)
F 0309
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
Provide necessary care and services to maintain the highest well being of each resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview conducted during a Standard survey completed on 3/29/17 it was determined that the
facility did not ensure that each resident must receive and the facility must provide the necessary care and services to
attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the
comprehensive assessment and plan of care. Specifically, one (Resident #53) of 27 residents reviewed for quality of care
related to physician's orders had issues involving stool specimens that were not obtained as order by the Physician.
1. Resident #53 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set
(MDS -
an assessment tool) dated 1/16/17 revealed that the resident is cognitively intact, understood and understands.
Additionally, the resident required extensive assist from two staff members for transfers and ambulation.
Review of laboratory (lab) results dated 3/13/17 revealed the resident's red blood cell count (RBC) was 2.55 (normal 3.8 to
5.10), hemoglobin was 7.1 (normal 11.7 - 15.5), and hematocrit was 21.4 (normal 35-45).
Review of a Physician's Order Sheet dated 3/20/17 revealed an order to obtain three occult blood (OB) stool samples (lab
test used to check stool for hidden (occult) blood).
Review of the Daily Unit Report (24 - hour report) dated 3/20/17 revealed a notation that stool OB x 3 needed for Resident
#53. Continued review of the Daily Unit Reports through 3/28/17 revealed additional notations on 3/27/17 and 3/28/17 that
stool for OB needed for Resident #53.
Review of a BM Record (bowel movement record) revealed the resident had 10 bowel movements between 3/20/17 and 3/27/17.
Review of the March 2017 Medication Administration Record [REDACTED]. On 3/21, 3/24, 3/25 the 11:00 PM to 7:00 AM shift
documented unsuccessful attempts.
During an interview on 3/28/17 at approximately 9:21 AM, Licensed Practical Nurse (LPN #1) stated that she should have
written that a stool sample was needed on the white board (dry erase board used for notifications) for the certified nurse
aides (CNA's) to see. but she did not. LPN #1 stated that she also writes it on the 24-hour report. If the sample is not
obtained, it should be carried over to the next 24-hour report. LPN #1 then stated that the nurses should be reviewing the
BM record. LPN #1 also stated that the nurses should be telling the CNA's about needing a stool sample. She stated that the
resident is uses a bed pan for toileting needs. The LPN further stated that if they are not able to obtain a sample after a
few days she would expect her staff to call the physician.
During an interview on 3/28/17 at approximately 9:13 AM, CNA #2 the CNA stated that he was not aware that the resident
needed a stool sample and that no one told him.
During an interview on 3/28/17 at approximately 9:17 AM, LPN #2 stated that she would normally tell her CNA's that a stool
sample was needed from the resident. LPN #2 could not recall if or whom she told.
During interview on 3/28/17 at approximately 9:19 AM, CNA #1 stated that she didn't know the resident needed a stool sample.
During an interview on 3/28/17 at approximately 1:03 PM, the Nurse Practitioner (NP) stated that it's a reasonable
expectation to obtain a stool sample within a few days if the resident is regularly having bowel movements.
During an interview on 3/29/17 at approximately 10:29 AM, the Director of Nursing (DON) revealed that the she expects the
staff to obtain the stool samples within a few days if the resident is regular and if they could not obtain it to get a
discontinue order from the physician.
Review of the facility policy entitled Laboratory Orders and Transcription dated 6/16/15 revealed that the facilities will
provide and obtain laboratory services when ordered by the physician or nurse practitioner and will ensure efficient and
effective expediting of results with appropriate follow up.
415.12
F 0314
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed
sores.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review conducted during the Standard Survey completed on 3/29/17, the facility did not ensure
that a resident having pressure ulcers receives the necessary treatment and services to promote healing and prevent new
ulcers from developing. One (Resident #133) of three residents reviewed for pressure ulcers had issues involving the lack
of implementing treatment orders for the prevention of skin breakdown to the peri-wound of a healing Stage IV sacral (area
above the tail bone to right and left buttocks) pressure ulcer.
The finding is:
1. Resident #133, admitted on [DATE] and re-admitted on [DATE], has [DIAGNOSES REDACTED]. Review of the Minimum Data
Set
(MDS - a resident assessment tool) dated 1/9/17 revealed the resident has no cognitive impairment, understands and is
understood. The resident requires total staff assistance for bed mobility, and toilet use, has a urinary catheter (tube
inserted into the bladder to drain urine) and is always incontinent of bowel.
Review of the Physician Admission History & Physical dated 11/18/16 revealed the resident re-entered the facility on 11/1/16
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99)
Previous Versions Obsolete
Event ID: YL1O11 Facility ID: 335663 If continuation sheet
Page 1 of 4

2. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED:2/12/2018
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
(X1) PROVIDER / SUPPLIER
/ CLIA
IDENNTIFICATION
NUMBER
335663
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
03/29/2017
NAME OF PROVIDER OF SUPPLIER
SAFIRE REHABILITATION OF SOUTHTOWN, L L C
STREET ADDRESS, CITY, STATE, ZIP
300 DORRANCE AVENUE
BUFFALO, NY 14220
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0314
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
(continued... from page 1)
with a Stage IV sacral pressure ulcer measuring 5 centimeter (cm) Length ( L) x 3 cm Width (W) x 2 cm Depth (D) with a pink
base and tunneling (passage way of tissue destruction under the surface) at the two o'clock position.
Review of a physician's orders [REDACTED]. Apply Skin Prep (topical application that toughens skin and enhances adherence of
dressing) to the peri-wound before applying dressing and [MEDICATION NAME] (antifungal) powder to buttocks and thighs every
shift for fungal rash.
Review of the hospital-based Wound Clinic/Consult Physician order [REDACTED]. The order for the Zinc Barrier cream dated
3/20/17 was not transcribed during the medical record review dated 3/24/17.
Observation on 3/24/17 at 11:44 AM revealed the Licensed Practical Nurse (LPN) #5 cleansed the resident's wound with normal
saline using gloved hands and fingers to navigate the 4 x 4 dressing to cleanse the wound bed, packed the wound with
Alginate dressing using her gloved hands and fingers to pack the wound and undermining (destruction of tissue under the
wound edges) visible, and covered the wound with an Allevyn. During the observation, the resident's buttocks and upper
thighs were bright red, with multiple excoriations and two noticeable open areas on the right and left buttock; the left
buttock open area was weeping a moderate amount or serous fluid visible. LPN #5 applied [MEDICATION NAME] powder on the
reddened areas; however, no barrier cream was applied to the buttocks or thighs.
During an interview on 3/24/17 at 3:56 PM, LPN #4 Unit Manager (UM) stated that she received the end of shift report from
the LPN Treatment Nurse who did not report any abnormal findings. LPN #4 UM stated that the Treatment Nurses and Certified
Nurse Aides (CNA's) are responsible to inform her of any new open skin issues. During the interview LPN #4 UM reviewed the
end of shift report and stated there was nothing regarding the resident on the report for the 7:00 AM - 3:00 PM shift.
Further resident observation with the Registered Nurse (RN) #2 acting Director of Nursing (DON) on 3/24/17 at 4:08 PM, RN #2
DON stated that the resident had an extremely reddened buttocks and upper thighs with two new open skin issues not present
during the previous skin evaluation. RN #2 DON stated that he would obtain new skin treatment orders for the resident.
During an interview on 3/24/17 at 4:18 PM, LPN #5 stated that when she applied the [MEDICATION NAME] powder on the
resident's reddened buttocks and upper thighs she did not notice any open skin wounds.
Review of the RN Weekly Wound documentation dated 3/24/17 by RN #2 DON revealed the resident had two new excoriations one
on
the right buttock measuring 4 cm L x 0.5 cm W with 100% (percent) epithelized (formation of surface area of skin) tissue
and one on the left buttock measuring 0.4 cm L x 0.4 cm W with 100% epithelized tissue.
During an interview on 3/27/17 at 9:39 AM, the facility's NP stated that the resident goes to the hospital-based Wound
Clinic every two weeks and the facility follows their treatment recommendations. The NP stated when the resident returns
from the clinic the nurses transcribe the orders and the treatment sheets get placed in the provider's order for signature.
The NP stated although she signed the 3/20/17 consult, she assumed the nurses had already transcribed the order for the
Zinc barrier cream. The NP inspected the resident's skin during the interview and stated that the right buttock was not
healed.
415.12(c)(2)
F 0323
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
Make sure that the nursing home area is free from accident hazards and risks and provides
supervision to prevent avoidable accidents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review conducted during the Standard survey completed on 3/29/17, the facility
did not ensure that the resident environment remains as free from accident hazards as is possible. Specifically, two
(Residents #8 and 189) of four residents reviewed for accidents had issues with a loose side rail and a bathroom floor door
threshold was in disrepair.
The findings are:
1. Resident #8 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS
-
resident assessment tool) dated 1/31/17 revealed the resident is cognitively intact, is understood and understands.
During an observation on 3/23/17 at 9:39 AM, the left 1/2 side rail on the bed was loose and moved approximately two inches
side to side.
During an observation on 3/27/17 at 9:58 AM, the left 1/2 side rail on the bed was loose and moved approximately two inches
side to side.
During an interview on 3/27/17 at 9:58 AM at the time of the observation, the resident stated the side rail has been loose
for a while and that she uses the side rail every day to help pull herself up.
Review of a Physician's Order Sheet dated 2/22/17 revealed an order for [REDACTED].
Review of the Comprehensive Care Plan dated 2/6/17 revealed the resident required extensive assist of one staff member for
bed mobility with an intervention to utilize 1 1/2 side rail for T & P.
Review of an Interdisciplinary Restraint assessment dated [DATE] revealed the following recommendations: Resident educated
and can benefit from 1/2 side rail for T & P.
Review of an Occupational Therapy Progress Summary and Goal Tracking Report dated 2/22/17 revealed nursing recommendations
to include 1/2 side rail for T & P.
During an interview on 3/27/17 at 1:56 PM, the Registered Nurse (RN#1), Unit Manager (UM)stated she would call maintenance
to come and fix the side rail right away.
During an observation on 3/28/17 at 8:39 AM, the left side rail on bed was very loose. At the time of the observation the
resident stated, nobody came in yesterday to look at it or fix the rail.
During an interview at 3/28/17 at 8:40 AM RN #1 UM, looked at the side rail and stated that the side rail is too loose and
needed to be fixed. The RN stated that she called maintenance yesterday and does not know why it was not fixed. She was
going to call them again and write it in the Maintenance Work Request book. The RN further stated that they would need to
swap the bed out because the rail is attached to the bed and cannot be removed or tightened.
During an interview on 3/28/17 at 8:41 AM, the maintenance worker stated, that type of rail is always loose and there is no
way to tighten it. The maintenance worker further stated that he just spoke to RN #1 and he will exchange the bed with a
different one as that rail is attached directly to the bed directly and cannot be removed.
Review of the Maintenance Work Request log dated 3/28/17 revealed an entry for a new bed.
Review of the policy entitled Bed Safety dated 11/9/16 revealed the facility shall try to prevent deaths/ injuries from the
beds and related equipment (including side rails). The facility shall promote the following approaches:
a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify
risks and problems.
c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications.
d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety
guidance to ensure proper fit.
2. Resident #189 has [DIAGNOSES REDACTED]. The resident is independent with a rolling walker for ambulation.
During an observation on 3/22/17 at approximately 10:57 AM revealed that there were approximately 40 one inch square tiles
missing at the threshold of the bathroom door. Leaving a gap in the floor approximately six inches wide and between five to
ten inches long.
Additional observation on 3/27/17 at approximately 1:47 PM revealed the threshold of the bathroom floor remained in
disrepair.
During an interview on 3/28/17 at approximately 1:50 PM, revealed the resident can walk to the bathroom using her walker.
The resident stated it's a miracle I haven't tripped over that yet, I try to walk around that area so I don't trip.
During an interview on 3/28/17 at approximately 10:30 AM, RN #1 UM looked at the threshold and stated the missing tiles
could be a possible accident hazard if the resident wasn't paying attention or disoriented. She also stated that she would
get maintenance to fix the floor right away.
During an interview on 3/28/17 at approximately 10:35 AM, the Maintenance Supervisor stated that the area could be a trip
hazard and that it would get fixed as soon as possible. The Maintenance Supervisor also stated he did not know how long the
floor was like that, and added that the floor looked like someone attempted to fix it and only part of it was completed.
During an additional observation on 3/28/17 at approximately 12:00 PM revealed that the area of missing tiles was repaired
FORM CMS-2567(02-99)
Previous Versions Obsolete
Event ID: YL1O11 Facility ID: 335663 If continuation sheet
Page 2 of 4

3. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED:2/12/2018
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
(X1) PROVIDER / SUPPLIER
/ CLIA
IDENNTIFICATION
NUMBER
335663
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
03/29/2017
NAME OF PROVIDER OF SUPPLIER
SAFIRE REHABILITATION OF SOUTHTOWN, L L C
STREET ADDRESS, CITY, STATE, ZIP
300 DORRANCE AVENUE
BUFFALO, NY 14220
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0323
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
(continued... from page 2)
with cement.
Review of the facility policy Preventative Maintenance dated 2/1/17 revealed that routine inspections promote safety
throughout the facility and aid in keeping equipment in good working order.
415.12(h)(1)(2)
F 0325
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
Make sure that each resident gets a nutritional and well balanced diet, unless it is not
possible to do so.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review conducted during the Standard survey completed 3/9/17, the facility did not ensure that
a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the
resident's clinical condition demonstrates that this is not possible. Specifically, two (Residents #131,184) of four
residents reviewed for nutrition had issues involving a delay in implementation of planned nutritional supplements, the
lack of timely nutritional interventions for significant weight loss and the lack of care plan revisions to address the
significant weight loss.
The findings are:
1. Resident #131 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set
(MDS -
resident assessment tool) dated 12/17/16 revealed the resident is cognitively intact, is understood and understands.
Review of the Weight Record revealed the following weights:
12/07/16 - 207.4 pounds (lbs.) (Admission weight)
12/13/16 - 199.75 lbs (showing a 7.65 lbs / 3.7 % (percent) decrease in six days)
12/20/16 - 194.4 lbs (showing a 13 lbs / 6.3 % decrease in 13 days)
12/27/16 - 192 lbs (showing a 15.4 lbs / 7.4 % decrease in 20 days)
Review of Nutritional assessment dated [DATE] revealed weight variance stable, [MEDICATION NAME] level (a blood protein) 3.5
(reference range 3.6-5.1). The documented plan included to provide the resident with 8 ounces of fortified milk at
breakfast.
Review of the Meal Acceptance Sheet for the week of 12/12/16 to 12/18/16 revealed no documentation that resident was
receiving the eight ounces of fortified milk at breakfast. The fortified milk was not listed on the sheet.
Review of the Meal Acceptance Sheet for Week of 12/19/16 to 12/25/2016 revealed the fortified milk was listed on the sheet
and the resident was accepting less than 50 %.
Review of a Dietary Progress Note dated 12/23/16 documented lab results from 12/21/16, [MEDICATION NAME] level down to 3.3.
PO (by mouth) intakes 25-100% meals. Refuses - 50% fortified milk. Resident on weekly weights.
Review of the entire medical chart revealed no other dietary documentation.
Review of physician progress notes [REDACTED]. Physical exam weight documented as NA (not applicable).
Review of the Comprehensive Care Plan dated 12/12/16 revealed under Nutritional Status a goal that resident will maintain
stable weight without significant weight change throughout next review. Interventions include to provide eight ounces of
fortified milk.
2. Resident #184 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE]
revealed the resident is cognitively intact, is understood and understands.
Review of the Weight Record revealed the following weights:
2/10/17 - 205 lbs (Admission weight)
2/14/17 - 193.6 lbs (showing a 11.4 lbs / 5.6 % decrease in 4 days)
2/21/17 - 193.3 lbs (showing a 11.7 lbs / 5.7% decrease in 11 days)
2/28/17 - 191.4 lbs (showing a 13.6 lbs / 6.6% decrease in 18 days)
Review of a Nutritional assessment dated [DATE] revealed weight variance stable, [MEDICATION NAME] level (a blood protein)
2.6 (reference range 3.6-5.1). The documented plan included, D/T (due to) low [MEDICATION NAME] will receive will receive
fortified milk at all meals.
Review of the entire medical chart revealed no other dietary documentation.
Review of Adult Nurse Practitioner Note dated 2/28/17 revealed no documented evidence addressing the weight loss.
Review of the Meal Acceptance Sheet for Week of 2/14/17 through 2/19/17 revealed no documentation that resident was
receiving the eight ounces of fortified milk at all meals. The fortified milk was not listed on the sheet.
Review of the Meal Acceptance Sheet for Week of 2/20/17 to 2/26/2017 revealed the fortified milk was listed on the sheet and
the resident was accepting an average of approximately 75 - 100 %.
Review of the Comprehensive Care Plan dated 2/15/17 revealed under Nutritional Status a goal that resident will maintain
stable weight without significant weight change throughout next review. Interventions include to provide fortified milk.
During an interview on 3/28/17 at 9:31 AM the Diet Technician stated I monitor weekly weights by recording them on the
weight grid sheets that are in the charts every week. If we need a reweight I ask the nurse and the nurse will ask the
aides to do it. The reason why the fortified milk was not on the intake sheets is because I only print the sheets (meal
acceptance) up weekly. Every time there would be a nourishment change, I would have to print up new sheets.
During an interview on 3/28/17 at 9:38 AM, the Registered Dietitian stated We document weights monthly. We should be
documenting the weekly weights and looking closer at them. We should have addressed the weight loss, but we didn't. I
question how accurate admission weights are and that is why I didn't document anything about the weight losses. We should
have also addressed the weight loss on the care plans and with the physician. The fortified milk should have been added to
the intake sheets right away when we initiated it and not wait till they get printed the next week. We will need to go and
hand write them on the sheets.
Review of policy entitled Nutrition (Impaired) Unplanned Weight Loss- Clinical Protocol dated 2/1/17 revealed the following
the threshold for significant unplanned and undesired weight loss will be based on the following criteria:
One month- 5% weight loss is significant; greater than 5% is severe.
Three months- 7.5% weight loss is significant; greater than 7.5 % is severe.
Six months- 10% weight loss is significant; greater than 10% is severe.
In addition, the Physician will consider whether any assessment including additional diagnostic testing is indicated to help
clarify the severity or consequences of weight loss and/ or impaired nutrition.
Review of the policy entitled Nutritional assessment dated [DATE] revealed an individualized care plans shall address, to
the extent possible:
a. The identified causes of impaired nutrition.
b. The resident's personal preferences.
c. Goals and benchmarks for improvement.
d. Timeframes and parameters for monitoring and reassessment.
e. Resident behavior i.e. weight refusal.
Additionally, The IDT (Interdisciplinary Team) will discuss resident status (i.e. weight gain or loss) at the am meeting and
weekly weight meeting.
415.12(i)(1)
F 0334
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
Develop policies and procedures for influenza and pneumococcal immunizations.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review conducted during the Standard Survey completed on 3/29/17, the facility did not develop
policies and procedures that ensure that each resident is offered a pneumococcal immunization, unless the immunization is
medically contraindicated or the resident has been immunized with the vaccine. Two (Residents #8, 175) of five residents
reviewed for influenza and pneumococcal vaccination had issues with the lack of administration of the influenza vaccination
(Resident #175), and lack of screening the status for influenza and pneumococcal vaccination (Resident #8).
The findings are:
1. Resident #175, admitted on [DATE] has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident
assessment
FORM CMS-2567(02-99)
Previous Versions Obsolete
Event ID: YL1O11 Facility ID: 335663 If continuation sheet
Page 3 of 4

4. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED:2/12/2018
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
(X1) PROVIDER / SUPPLIER
/ CLIA
IDENNTIFICATION
NUMBER
335663
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
03/29/2017
NAME OF PROVIDER OF SUPPLIER
SAFIRE REHABILITATION OF SOUTHTOWN, L L C
STREET ADDRESS, CITY, STATE, ZIP
300 DORRANCE AVENUE
BUFFALO, NY 14220
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0334
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
(continued... from page 3)
tool) dated 1/29/17 revealed that the resident has no cognitive impairment, understands and is understood.
Review of the Influenza Immunization Form dated 1/19/17 revealed the resident signed a consent to receive the influenza
immunization; however, review of the resident's medical record on 3/23/17 revealed the resident had not received the
influenza vaccination.
During an interview on 3/23/17 at approximately 7:45 AM, the Registered Nurse (RN) Unit Manager (UM) stated that the
resident had not received the vaccine and should have had it administered In January.
Review of the facility's policy entitled Immunization: Influenza and (Flu) Prevention and Disease Transmission revealed that
current and newly admitted residents will be offered the influenza vaccine during the current annual influenza season.
Vaccines will be ordered by the physician and administered when the vaccine is available.
2. Resident #8, admitted on [DATE] has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident
has
no cognitive impairment, understands and is understood.
Review of the resident's medical record on 3/23/17 revealed that it did not contain any information regarding the resident's
status for influenza and pneumococcal vaccinations.
During an interview on 3/23/17 at approximately 7:45 AM, the RN UM stated that the resident should have been screened upon
admission and she would screen the resident's immunization status immediately.
Review of the facility's policy entitled Immunization: Influenza and (Flu) Prevention and Disease Transmission dated
10/25/16 revealed that current and newly admitted residents will be offered the influenza vaccine during the current annual
influenza season. Vaccines will be ordered by the physician and administered when the vaccine is available.
Review of the facility's policy entitled Immunization: Pneumococcal Vaccination (PPV) of Residents dated 2/1/17 revealed
that all residents over age 65 should receive the pneumococcal vaccine and each resident's pneumococcal immunization status
will be determined upon admission and documented in the resident's medical record.
415.19(a)(1)
FORM CMS-2567(02-99)
Previous Versions Obsolete
Event ID: YL1O11 Facility ID: 335663 If continuation sheet
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