Inspection Reports for
Achieve Rehab and Nursing Facility
170 Lake Street, Liberty, NY, 12754
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Inspection Report — Mar 30, 2026
Complaint Investigation State
Date: Mar 30, 2026
Visit Reason
State-compiled facility profile showing 7 inspections from 2022 to 2026 with deficiency and complaint history.
Complaint Details
The state logged 50 complaints about this facility; 9 led to on-site inspections. The facility received 38.6 complaints per 100 beds versus a statewide rate of 57.4, with 17 citations resulting from those complaints.
Findings
Across 7 inspections, 5 resulted in citations totaling 42 deficiencies primarily related to standard health and life safety code issues. The facility had 50 complaints with 9 on-site inspections and no formal enforcement actions.
Citations (39)
Standard Health Citation — quality of care: Facility Assessment deficiency noted with isolated scope.
Standard Health Citation — quality of care: Resident Records - Identifiable Information deficiency noted with pattern scope.
Standard Health Citation — quality of care: Quality Of Care deficiency noted with isolated scope.
Standard Health Citation — quality of care: Abuse, Neglect, And Exploitation Training deficiency noted with isolated scope.
Standard Health Citation — quality of care: Accuracy Of Assessments deficiency noted with isolated scope.
Standard Health Citation — quality of care: Department Criminal History Review deficiency noted with pattern scope.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficiency noted with pattern scope.
Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary deficiency noted with pattern scope.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices deficiency noted with pattern scope.
Standard Health Citation — quality of care: Infection Prevention & Control deficiency noted with pattern scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficiency noted with isolated scope.
Standard Health Citation — quality of care: Maintains Effective Pest Control Program deficiency noted with pattern scope.
Standard Health Citation — quality of care: Nurse Aide Peform Review-12 Hr/yr In-service deficiency noted with pattern scope.
Standard Health Citation — quality of care: Nutritive Value/appear, Palatable/prefer Temp deficiency noted with isolated scope.
Standard Health Citation — quality of care: Protection/management Of Personal Funds deficiency noted with isolated scope.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notif deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Cooking Facilities deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Corridor - Doors deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Elevators deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Fire Drills deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storag deficiency noted with isolated scope.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Smoking Regulations deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiency noted with pattern scope.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices deficiency noted with isolated scope.
Standard Health Citation — quality of care: Care Plan Timing And Revision deficiency noted with isolated scope.
Standard Health Citation — quality of care: Infection Control deficiency noted with isolated scope.
Standard Health Citation — quality of care: Maintains Effective Pest Control Program deficiency noted with isolated scope.
Standard Health Citation — quality of care: Quality Of Care deficiency noted with isolated scope.
Standard Health Citation — quality of care: Transfer And Discharge Requirements deficiency noted with isolated scope.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer deficiency noted with isolated scope.
Life Safety Code Citation — NFPA requirements: Develop Ep Plan, Review And Update Annually deficiency noted with widespread scope.
Life Safety Code Citation — NFPA requirements: Egress Doors deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extens deficiency noted with isolated scope.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Local, State, Tribal Collaboration Process deficiency noted with widespread scope.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers deficiency noted with isolated scope.
Life Safety Code Citation — NFPA requirements: Smoke Detection deficiency noted with pattern scope.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation deficiency noted with isolated scope.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 42
Inspections with violations: 5
Inspections without violations: 2
Total complaints: 50
On-site complaint inspections: 9
Citations issued from complaints: 17
Total enforcement actions: 0
Inspection Report — Jan 16, 2025
Abbreviated Survey CMS
Date: Jan 16, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with wound care treatment standards for residents, specifically reviewing treatment and care for skin conditions.
Findings
The facility failed to provide appropriate wound care treatment consistent with professional standards for one resident, resulting in worsening wounds and hospital transfer. Multiple physician orders for wound care treatments were not consistently completed or documented, and there was a failure in communication and documentation regarding treatment refusals and omissions.
Citations (1)
F 0684: The facility did not ensure resident received treatment and care consistent with professional standards for skin conditions. Treatment Administration Records showed multiple omissions of wound care treatments from March to April 2023, leading to worsening wounds and hospital transfer.
Report Facts
Treatment omissions: 4
Treatment omissions: 11
Treatment omissions: 4
Treatment omissions: 12
Treatment omissions: 10
Treatment omissions: 9
Wound measurements: 5
Wound measurements: 8
Wound measurements: 8
Wound measurements: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported observation of worsening wound and use of Unna boot dressings |
| Nurse Practitioner #1 | Nurse Practitioner | Provided care for Resident #1 starting July 2023 and noted non-compliance with care |
| Registered Nurse Supervisor/Unit 2 Manager | Registered Nurse Supervisor/Unit 2 Manager | Stated undocumented blank areas on Treatment Administration Record indicated treatments were not done |
| Assistant Director of Rehab | Assistant Director of Rehab | Involved in shrinker process and noted resident non-compliance with rehab and nursing care |
| Wound Care Nurse Practitioner #2 | Wound Care Nurse Practitioner | Noted resident non-compliance and failure of nurses to document treatments properly |
| Former Wound Care Nurse Practitioner | Former Wound Care Nurse Practitioner | Stated resident non-compliance and that facility should have been informed of missed treatments |
| Former Director of Nursing | Former Director of Nursing | Reported awareness of resident's wounds and non-compliance with wound care and insulin |
Inspection Report — Oct 23, 2024
Recertification CMS
Date: Oct 23, 2024
Visit Reason
The inspection was conducted as part of recertification and abbreviated surveys from 10/16/24 to 10/23/24 to assess compliance with regulatory requirements.
Findings
The facility had multiple deficiencies including failure to safeguard residents' personal funds, inaccurate Minimum Data Set assessments, incomplete care plans, inadequate accident prevention and investigation, lack of annual performance appraisals for some Certified Nurse Aides, ineffective infection prevention and control program, pest control issues, and failure to provide required staff education on abuse, neglect, and dementia care.
Citations (8)
F 0567: The facility did not ensure residents had access to their personal funds on weekends, with documented instances of zero balances and missed documentation in the Reception Bank Log.
F 0641: The Minimum Data Set assessment inaccurately documented that Resident #280 had no bed or chair alarms despite a care plan indicating otherwise.
F 0656: The facility failed to develop and implement comprehensive care plans with measurable objectives for multiple residents, including cardiac, urinary tract infection, and respiratory care needs.
F 0689: The facility failed to ensure a safe environment and adequate supervision, resulting in a resident fall with injury, a choking incident leading to cardiac arrest, and improper transfer causing a wrist fracture.
F 0730: The facility did not complete annual performance appraisals for 4 of 5 Certified Nurse Aides reviewed.
F 0880: The infection prevention and control program was deficient, including improper use of transmission-based precautions, incomplete infection surveillance logs, and failure to implement appropriate isolation orders.
F 0925: The facility did not maintain an effective pest control program, with ongoing presence of cockroaches and gnats observed in resident areas despite pest control services.
F 0943: The facility failed to provide education on abuse, neglect, exploitation, dementia care, and misappropriation of resident property to a Certified Nurse Aide involved in a neglect incident.
Report Facts
Residents reviewed for personal funds: 1
Residents sampled for Minimum Data Set accuracy: 35
Certified Nurse Aides missing annual appraisals: 4
Residents positive for COVID-19: 13
Residents with infection control issues reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #13 | Certified Nurse Aide | Named in neglect incident causing wrist fracture and lack of required education |
| Registered Nurse #9 | Registered Nurse | Interviewed regarding Minimum Data Set and infection control precautions |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care plans, incident investigations, and infection control |
| Administrator | Administrator | Interviewed regarding incident investigations, infection control, and staff education |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control program deficiencies and surveillance |
| Director of Human Resources | Director of Human Resources | Interviewed regarding missing annual performance appraisals |
| Maintenance Director | Maintenance Director | Interviewed regarding pest control program and interventions |
Inspection Report — Oct 23, 2024
Annual Inspection CMS
Date: Oct 23, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 10/16/24 to 10/23/24 to assess compliance with regulatory requirements for Achieve Rehab and Nursing Facility.
Findings
The facility was found deficient in multiple areas including failure to safeguard residents' personal funds, incomplete care plans for multiple residents, inadequate accident prevention and investigation, lack of annual performance appraisals for certified nurse aides, improper medication storage and administration, food safety and temperature issues, ineffective pest control, and deficiencies in infection prevention and control practices.
Citations (9)
F 0567: The facility did not ensure residents had access to their personal funds on weekends, with missing documentation and insufficient funds available at the reception desk bank box.
F 0656: The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents' medical and nursing needs.
F 0689: The facility did not ensure a safe environment free from accident hazards, resulting in falls, injuries, and inadequate investigation of incidents for several residents.
F 0730: The facility did not complete annual performance appraisals for 4 of 5 certified nurse aides reviewed.
F 0761: The facility failed to ensure medications were stored according to professional standards; Resident #179 had physician-ordered inhalers and nasal sprays stored unsecured at bedside without physician orders for self-administration.
F 0804: Food served to Resident #70 was not held at palatable temperatures, with observed food temperatures below acceptable levels.
F 0812: The facility stored food items in the walk-in refrigerator and dry storage room that were undated and past expiration dates, risking food safety.
F 0880: The facility failed to maintain an effective infection prevention and control program, including improper use of transmission-based precautions and incomplete infection surveillance and tracking.
F 0925: The facility did not maintain an effective pest control program; insect and rodent traps with gnats and cockroaches were observed in Resident #70's room, and pest infestations persisted despite pest control services.
Report Facts
Residents positive for COVID-19: 13
Residents affected by deficiencies: 4
Food temperature: 82.2
Food temperature: 77.4
Expiration date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #13 | Certified Nurse Aide | Named in finding related to improper transfer causing resident injury. |
| Registered Nurse #9 | Registered Nurse | Interviewed regarding lack of cardiac care plan and infection control precautions. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan responsibilities, infection control, and medication storage. |
| Administrator | Administrator | Interviewed regarding infection tracking and pest control issues. |
| Director of Human Resources | Director of Human Resources | Interviewed regarding missing annual performance appraisals. |
| Maintenance Director | Maintenance Director | Interviewed regarding pest control program and improvements. |
Inspection Report — Oct 11, 2023
Abbreviated Survey CMS
Date: Oct 11, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety and supervision requirements, specifically related to preventing resident elopement and ensuring accident-free environments.
Findings
The facility failed to ensure adequate supervision and accident hazard prevention for one resident at risk of wandering and elopement. Resident #1 exited the facility undetected due to a missing wander guard and staff oversight, but was safely returned without injury.
Citations (1)
F 0689: The facility did not ensure adequate supervision and accident hazard prevention for Resident #1 who exited the facility independently without a wander guard in place. The resident was observed wandering outside the fence and was safely returned by staff.
Report Facts
Residents Affected: 3
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Recreation Aide | Observed and escorted Resident #1 back into the building | |
| Receptionist | Opened front door allowing Resident #1 to exit and did not follow elopement procedures | |
| Registered Nurse | Assessed Resident #1 after elopement with no injuries noted | |
| RN Supervisor | Conducted head-to-toe assessment of Resident #1 after incident | |
| Director of Nursing | Provided information on wander guard procedures and corrective actions |
Inspection Report — Sep 27, 2022
Annual Inspection CMS
Date: Sep 27, 2022
Visit Reason
The inspection was a Recertification Survey and Abbreviated Survey conducted to assess compliance with regulatory requirements for Achieve Rehab and Nursing Facility.
Findings
The facility was found deficient in multiple areas including inadequate discharge planning and documentation, failure to revise comprehensive care plans as required, inconsistent treatment and care according to physician orders, and ineffective pest control program. Specific issues included unsafe discharge practices for two residents, incomplete care plan revisions for two residents, failure to provide ordered treatments for venous stasis and contracture management, and presence of gnats in resident areas.
Citations (5)
F 0622: The facility did not ensure residents received safe and appropriate discharge. Resident #228 lacked a safe discharge plan and Resident #226's Patient Review Instrument was not completed timely for transfer.
F 0657: The Comprehensive Care Plan was not revised for Resident #98 to include prescribed hand rolls and knee splints, and for Resident #121 to reflect change from Full Code to Do Not Resuscitate status.
F 0684: Resident #55 did not receive Unna boot changes twice weekly as ordered, and Resident #98 did not consistently use prescribed hand rolls and knee splints.
F 0686: Resident #98's heel lift boots were not applied as ordered to prevent pressure ulcers, with missing documentation and observed absence of boots during care.
F 0925: The facility failed to maintain an effective pest control program, with multiple observations of gnats in resident rooms and hallways on unit 2 East, and no documented pest control actions taken.
Report Facts
Residents Affected: 2
Residents Affected: 2
Residents Affected: 2
Residents Affected: 1
Residents Affected: 4
Inspection Report — Mar 28, 2019
Annual Inspection CMS
Date: Mar 28, 2019
Visit Reason
The inspection was conducted as part of the facility's recertification survey to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification to resident representatives of hospital transfers, incomplete and outdated care plans, inadequate treatment to prevent dehydration, lack of passive range of motion therapy for residents with impaired mobility, and failure to act on consultant pharmacist recommendations.
Citations (6)
F 0623: The facility did not ensure resident representatives were notified in writing of hospital transfers for 5 residents. Notification was only done by phone without written documentation.
F 0656: The facility failed to develop and implement a complete care plan with measurable objectives and interventions for positioning, mobility, and catheter care for 2 residents.
F 0657: The facility did not update the care plan to include recent hospitalization for pneumonia for 1 resident, missing review and revision by the care team.
F 0684: The facility failed to provide timely treatment to prevent dehydration for 1 resident with poor fluid intake over five weeks, resulting in significant hypernatremia and dehydration.
F 0688: The facility did not ensure passive range of motion was performed for 1 resident with impaired mobility, despite care plan interventions.
F 0756: The facility did not ensure consultant pharmacist recommendations were acted upon by the primary care physician for 1 resident, including lack of laboratory testing and medication monitoring.
Report Facts
Residents affected: 5
Fluid intake: 814
Fluid intake goal: 1500
Sodium level: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor | Registered Nurse Supervisor | Stated that families are notified by phone but no written notification is sent for hospital transfers |
| Director of Nursing | Director of Nursing | Stated no system is in place to notify families in writing of hospital transfers |
| RN-UM #3 | Registered Nurse-Unit Manager | Interviewed regarding care plan deficiencies and PROM therapy |
| LPN assigned to Resident #120 | Licensed Practical Nurse | Interviewed regarding catheter care documentation |
| RN #4 | Registered Nurse | Interviewed regarding catheter care and dehydration signs for Resident #120 |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding lack of physician response to medication regimen review recommendations |
| Resident's Primary Care Physician | Primary Care Physician | Interviewed regarding disagreement with some pharmacist recommendations and documentation practices |
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