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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Achieve Rehab And Nursing Facility during CMS and state inspections, most recent first.
Failure to Protect a Resident from Sexual Abuse: A maintenance worker observed a visitor on top of a resident with hands under the resident’s blouse touching the resident’s breasts. The resident reported the visitor kissed them and continued after being told to stop. The resident had dementia, anxiety, schizophrenia, and encephalopathy, and later documentation noted severe insomnia. Staff assessments and the hospital exam found no visible trauma, but the event resulted in actual psychosocial harm.
Failure to maintain resident dignity during care and dining: an uncovered nephrostomy drain bag was visible from the hallway, a resident was observed wearing a ripped hospital gown, residents were served beverages in disposable plastic cups during meals, and a CNA stood while feeding a resident. The DON and other staff acknowledged the uncovered bag and the use of disposable cups, and the Administrator stated the cups did not promote dignity.
The facility failed to maintain a safe, clean, comfortable, and homelike environment across multiple units. Residents reported broken or noisy AC units, a sink that would not turn off, and a hot room, while surveyors observed a sharp sink edge, peeling wallpaper, damaged wall surfaces, and loose handrail end caps. Staff and the maintenance director acknowledged several of the issues and noted some were known or had been reported.
The facility failed to ensure that two residents who needed staff help with ADLs received consistent personal hygiene care and documentation. One resident who was dependent for toileting hygiene had multiple missed or undocumented toileting and 2-hour check entries across several months, while another resident who needed max assist with bathing was repeatedly observed with dirty long nails and overgrown facial hair, with missed or undocumented showers and no nail or shave care during bed baths. Staff interviews confirmed gaps in documentation and in the delivery of hygiene care.
Infection prevention and control lapses were observed involving missing legionella water management documentation, improper use of a shared glucometer without sanitizing between residents, failure of an LPN to perform hand hygiene between medication passes for two residents, and use of the same tissue to wipe both eyes after dorzolamide administration. The DON and Interim Infection Preventionist stated that hand hygiene should occur between residents, shared equipment should be sanitized between residents, and separate tissue should be used for each eye.
Delayed post-fall monitoring and imaging after unwitnessed fall. A resident with encephalopathy, AFib, CKD, and severe cognitive impairment fell from bed while receiving Eliquis and sustained a large skin tear to the right forearm. The incident report called for neuro checks and x-rays of the right shoulder and forearm, but there was no documented evidence that the one-hour neuro checks were ordered or completed in a timely manner, and no documented evidence that the imaging was completed before the resident was transferred to the ER.
A facility failed to ensure adequate supervision and safe use of assistance devices for two residents. One resident with Parkinson’s disease, dementia, and a recent fall had floor mats by the bed and a bedside commode blocking the bathroom door, while the record did not show a timely PT eval or care plan update after the resident returned from the hospital. A second resident with impaired cognition had a coffee maker in the room, but no documented assessment showed whether the resident could safely use it, and staff confirmed no such assessment had been completed.
Medication administration observations found a 6.25% error rate, exceeding the allowed threshold. An LPN gave a resident with Alzheimer’s disease and HTN the wrong dose of amlodipine after a recent order change was not properly matched to the blister pack, and another LPN prepared magnesium using a substitute strength without an order for a resident with hypomagnesemia, dementia, and diabetes. The RN unit manager and DON stated orders should be followed as written and substitutions should not be made without an order.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
Surveyors found that the facility’s most recent assessment of its 140-bed operation, including rehab, stepdown medically complex, and LTC dementia/chronic illness units, did not adequately specify how necessary resources are maintained for resident care. The assessment lacked a breakdown of bed capacity per unit and, under its staffing plan, only generally stated that staffing is based on census and acuity and reviewed each shift, with additional RNs scheduled for multiple admissions. It failed to identify contingency planning for non-emergency events that could affect direct care nurse staffing or other care resources, and it did not describe any plan to maximize recruitment and retention of direct care staff, resulting in a deficiency under 10NYCRR S415.26.
A resident with diabetes, peripheral vascular disease, and a history of amputation did not consistently receive or have documented wound care as ordered, with multiple omissions in treatment records and no evidence of proper communication of refusals or changes in condition to providers. Wound assessments showed worsening wounds, and staff interviews confirmed failures in documentation and communication, ultimately resulting in the resident's transfer to the hospital for evaluation.
During a survey, deficiencies were found in the facility's food storage practices. Observations revealed undated and expired food items in the walk-in freezer, refrigerator, and dry storage room. The Regional Director of Operations acknowledged the need for proper dating of opened products, which was not followed, leading to expired items being stored improperly.
The facility failed to develop comprehensive care plans for several residents, including one with cardiac issues, another with a urinary tract infection, and a third requiring respiratory care. Despite documented medical needs and treatments, care plans were not in place, as confirmed by nursing staff and the DON.
The facility failed to prevent accidents and ensure adequate supervision, resulting in incidents involving three residents. A resident at high risk for falls experienced an unwitnessed fall due to missing care plan interventions, leading to hospitalization. Another resident became unresponsive during dinner, with indications of choking, but the facility did not investigate the incident. Additionally, a resident requiring mechanical lift assistance was improperly transferred by a CNA, resulting in a broken wrist. The facility's lack of thorough investigations and adherence to care plans contributed to these deficiencies.
The facility did not complete annual performance appraisals for four CNAs, as required. The Director of Human Resources could not locate the reviews and explained that the process involves distributing forms based on hire dates, which should be completed and returned within a week. This process was not adhered to, resulting in the deficiency.
The facility failed to implement proper infection control precautions and maintain an effective infection surveillance plan. Staff did not adhere to required precautions for residents with infections, including those with COVID-19, and infection tracking logs were incomplete. The Infection Preventionist acknowledged issues with staff understanding of precautions and the delayed initiation of infection tracking logs.
A facility failed to maintain an effective pest control program, resulting in persistent infestations of gnats and cockroaches, particularly in a resident's room and common areas. Despite switching pest control companies, the issue persisted, as confirmed by staff and documented in the pest logbook.
A facility failed to accurately document a resident's status in the MDS assessment. The resident, with a history of falls and muscle weakness, had a care plan requiring bed and chair alarms. However, the MDS inaccurately noted the absence of these alarms. The MDS Coordinator admitted the oversight during an interview.
A facility failed to provide documented education on abuse, neglect, exploitation, dementia management, and misappropriation of resident property for a Certified Nurse Aide. This deficiency was discovered after a resident sustained a wrist fracture due to neglect. The aide, employed through a staffing agency, claimed to have received training, but neither the facility nor the agency could provide documentation. The facility's policy required such education, but records were unavailable, and the responsibility for training was unclear.
A resident with Asthma, Obstructive Sleep Apnea, and Anxiety was found with medications on their bedside table without proper physician orders or assessments for self-administration. Facility staff confirmed that medications at a resident's bedside require a physician's order and an assessment, which were not present in this case, indicating a failure to adhere to the facility's medication storage policy.
A facility failed to serve food at palatable temperatures for a resident with non-Alzheimer's dementia and malnutrition. The resident reported cold food, and a test tray confirmed low temperatures of 82.2°F for a hamburger and 77.4°F for green beans. The cook was unaware of the issue, while the Regional Director stated the food was at acceptable temperatures when it left the kitchen.
A facility failed to ensure residents had access to their personal funds on weekends, as required by policy. A resident reported that funds were often depleted by evening, with no plan to replenish them. The Reception Bank Log showed inconsistencies, and staff interviews revealed a lack of awareness and communication regarding the issue.
Failure to Protect a Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was adequately supervised and protected from sexual abuse. On 03/12/2026, a maintenance worker observed the visitor of another resident lying on top of the resident with their hands beneath the resident’s blouse while touching the resident’s breasts. The resident was later transferred to the hospital for evaluation and returned to the facility. The deficiency was cited under 10 NYCRR 415.4(b)(1)(i) and was described as causing actual psychosocial harm, but not Immediate Jeopardy. The resident involved had diagnoses including non-Alzheimer’s dementia, anxiety, schizophrenia, and encephalopathy. A quarterly MDS from 11/22/2025 documented the resident as cognitively intact and feeling down, depressed, or hopeless. The care plan for impaired cognition, initiated 01/05/2026, addressed confusion and family discussion about capabilities and needs, but there was no documented evidence that the comprehensive care plan addressed risk of abuse. The incident record documented that the visitor of the other resident had signed into the facility multiple times before the event and was later found on top of the resident. The resident told staff that the visitor kissed them, went under their blouse, and touched their breast, and that they asked the visitor to stop but the visitor did not stop. Staff assessments found no visible injury, and the hospital evaluation and rape kit found no trauma or abuse. Later documentation noted the resident reported severe difficulty sleeping with no sleep the previous night, and interviews with staff and police confirmed the visitor admitted to climbing on top of the resident and kissing them.
Failure to Maintain Resident Dignity During Care and Dining
Penalty
Summary
The facility failed to ensure residents’ rights to a dignified existence for multiple residents. Resident #11, who had diagnoses including multiple sclerosis, calculus of kidney, and hypothyroidism and was documented as having moderately impaired cognition, had a left nephrostomy tube with a care plan directing that the nephrostomy bag be changed weekly and output recorded each shift. During observations, the resident’s uncovered nephrostomy drain bag was hanging on the left side of the bed and visible from the hallway. The DON and a Nurse Manager stated the bag should have been covered and identified the uncovered bag as a dignity issue. Resident #125, who had diagnoses including Parkinson’s disease, type II diabetes mellitus, and depression and was cognitively intact, was observed sitting in a wheelchair wearing a hospital gown that was ripped in the front, and later was seen in the same torn gown on the elevator. In addition, during meal observations in multiple dining rooms, residents were served milk, juice, water, and cold drinks in disposable plastic cups. During lunch, a CNA was also observed standing while assisting Resident #97 with feeding. The Food Service Director stated nursing staff used disposable plastic cups for cold beverages, and the Administrator stated disposable plastic cups did not promote dignity.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment on four units reviewed for environmental conditions. On 1 East, residents reported malfunctioning air conditioners in their rooms, and one resident stated the room was hot and the air conditioner made a loud rattling noise, so they did not use it. An observation also found a rough, unfinished sink edge with an exposed sharp underside in one room. On 2 East, a resident reported a sink that would not turn off and was noisy, and repeated observations confirmed water running from the faucet that could not be stopped. On 2 West, an observation found peeling wallpaper under a sink and six loose handrail end caps in the hallway between rooms. On 1 West, the wall and wallpaper in the common area near the sink were damaged and peeling. Staff interviews confirmed that maintenance requests could be submitted electronically, and the maintenance director acknowledged awareness of some issues, including the dripping sink and air conditioning problems, while also stating the sharp sink edge and loose handrail end caps needed repair.
Failure to Provide and Document ADL Hygiene Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain personal hygiene. For one resident with diagnoses including left leg below-knee amputation, acute congestive heart failure, and acute respiratory failure with hypoxia, the annual MDS documented intact cognition and dependence on staff for toileting hygiene. The care plan also identified dependence on two staff members for toileting hygiene, yet the CNA documentation survey reports for January through April 2026 showed multiple shifts without documented toileting hygiene or every-two-hour resident checks, despite the facility policy requiring CNAs to sign the ADL flow sheet at the end of each shift. During interview, the resident stated CNAs were not checking every two hours and that they had to ring the call bell when needed, with delays in being cleaned even after speaking with CNAs. A unit manager stated that all staff were expected to document every shift and that if something was not documented, it did not happen; if a task was not completed, staff were expected to document why. The DON similarly stated that all documentation was expected each shift and that if it was not documented, it did not occur. A second resident with diagnoses including atrial fibrillation, peripheral vascular disease, and ischemic heart disease required maximum assistance with toileting hygiene and bathing per the admission MDS. The record contained no plan of care addressing ADL needs, and the CNA Kardex indicated showers were scheduled twice weekly with substantial assistance. The resident stated they wanted their nails cut and face shaved because they were dirty and long, and observations on three occasions showed long facial hair, long nails with brown substance under the nails and cuticles, and a urine odor in the room. CNA assignment sheets for April showed missed or undocumented shower opportunities, and CNAs stated they did not provide nail care or shaving during bed baths and did not always inform the nurse when care was missed.
Infection Prevention and Control Lapses During Equipment Use, Hand Hygiene, and Eye Drop Administration
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Review of the legionella logs on 05/20/2026 showed that a water management plan was missing and not provided at the time of survey. During an interview, the Director of Maintenance stated that the legionella water management plan could not be located. During medication administration observations, an LPN used a community glucometer on one resident and then prepared to use the same glucometer on another resident without sanitizing it first, and the surveyor stopped the nurse before the second fingerstick was performed. In another observation, an LPN administered medications to one resident and then prepared and administered medications to another resident without sanitizing hands between residents. The nurse stated they were distracted and did not perform hand hygiene between the two residents. The Interim Infection Preventionist and DON stated that nurses should sanitize their hands between residents when medications are administered, shared equipment should be sanitized between residents, and separate tissue should be used for each eye when administering eye drops. During an observation of dorzolamide eye drop administration, an LPN used the same tissue to wipe both eyes after administration.
Delayed post-fall monitoring and imaging after unwitnessed fall
Penalty
Summary
The facility failed to ensure that Resident #153 received treatment and care in accordance with professional standards of practice after an unwitnessed fall while the resident was receiving Eliquis. Resident #153 had diagnoses including encephalopathy, atrial fibrillation, and chronic kidney disease, and the admission MDS documented severe cognitive impairment and need for staff assistance with activities of daily living. The incident report documented that the resident was found on the floor next to the bed with a large 7-8 centimeter skin tear to the anterior right forearm, was assessed for injuries, and was returned to bed with close monitoring due to confusion and lack of safety awareness. The incident report also documented immediate interventions of pain assessment, range of motion assessment, right shoulder and right forearm x-rays to rule out fracture, and safety and neuro checks for 24 hours. However, there was no documented evidence that a physician order was placed timely for the one-hour neuro checks or for the radiographic imaging of the right shoulder and right forearm as described in the incident report. The physician order for one-hour neuro checks was not documented until later that day, and there was no documented evidence that neuro checks were completed between the time of the fall and 1:00 PM. There was also no documented evidence that the ordered right shoulder and right forearm imaging was completed before the resident was transferred to the hospital. The practitioner progress note later documented the chief complaint as a fall from bed and that the family requested transfer to the Emergency Room. During interviews, the family stated the facility did not adequately evaluate the resident after the fall and reported bruising on the right side of the body, while the nurse practitioner stated the expectation was that radiographic imaging would be performed to rule out fractures.
Failure to Ensure Safe Supervision and Hazard-Free Resident Environment
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices consistent with resident needs to prevent accidents for two residents. For one resident with Parkinson’s disease, dementia, and a history of falls, the record showed a fall in the bathroom that resulted in bruising above the right eye and rib fractures. After the resident returned from the hospital, the CNA Kardex documented maximum assistance for transfers, but the comprehensive care plan was not updated to reflect that change. The record also did not show a timely PT evaluation, and the resident’s room contained floor mats by the bed and a bedside commode positioned by the bathroom door. During observations, the resident was seen with a wheelchair in the doorway, the bedside commode next to the bathroom door, and floor mats placed on both sides of the bed. The resident stated they were using the bathroom independently and did not use the bedside commode. Staff interviews confirmed the resident was toileting independently and walking to the bathroom, while one LPN stated the floor mat and commode blocking the bathroom door would be a hazard. The DON stated the floor mats were not part of the plan of care and was unsure who placed them. For a second resident with encephalopathy, low back pain, depression, and impaired cognition, the care plan documented cognitive impairment and impaired thought processes, but there was no documented assessment to determine whether the resident could safely use the coffee maker in the room. Observations showed a coffee maker with supplies in the resident’s room, and it lacked an inspection sticker. Staff stated the resident did not use the coffee maker, but family members used it during visits and the resident could potentially attempt to make coffee. The RN unit manager and DON confirmed no assessment process had been completed for the resident’s safe use of the coffee maker.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent during medication administration observations, with 2 errors identified in 32 opportunities for error, resulting in a 6.25 percent error rate for 2 of 8 residents observed. The facility’s medication administration policy required nurses to follow the rights of medication administration, including the right dose and right medication. One error involved a resident with Alzheimer’s disease, asthma, and hypertension, whose quarterly MDS documented severely impaired cognition and hypertension. During observation, an LPN administered amlodipine besylate 2.5 mg even though the physician order called for 5 mg daily for hypertension. The LPN stated the order had recently changed, there was no alert on the packaging, and the blister pack containing 2.5 mg tablets had not been removed from the medication cart. A second error involved a resident with hypomagnesemia, dementia, and diabetes, whose quarterly MDS documented severely impaired cognition and hypomagnesemia. During observation, an LPN prepared magnesium for administration and stated the facility only kept magnesium 500 mg in stock, so one tablet would be given instead of two 250 mg tablets. When the surveyor counted the tablets in the medication cup, one extra tablet was present; the LPN stated two tablets had been drawn up in error and one was removed. The physician order required magnesium gluconate 250 mg, 2 tablets daily. Interviews with the RN unit manager and DON confirmed that orders should be followed as written and checked prior to administration, and that substitutions should not be made without an order.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Inadequate Facility-Wide Assessment of Resources and Staffing Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document an adequate facility-wide assessment that determines what resources are necessary to care for residents competently during day-to-day operations and emergencies. During an Abbreviated Survey, record review of the most recent facility assessment, dated on an unspecified date and reviewed by the QAPI Committee on 09/04/2025, showed that the assessment did not sufficiently identify how the facility maintains necessary resources for resident care. The assessment described the facility as a 140-bed SNF with four nursing units (one rehabilitation unit, one stepdown medically complex unit, and two LTC units for residents with dementia and other chronic illnesses), but it did not provide a breakdown of bed capacity per unit. Under the staffing plan section, the assessment stated that staffing is based on resident census and acuity, is reviewed prior to each shift, and that the facility intends to assign the same staff to units and schedule additional RNs for multiple admissions. However, the assessment did not adequately identify contingency planning for events that do not trigger the formal emergency plan but could still affect resident care, such as issues with availability of direct care nurse staffing or other needed resources. Additionally, the assessment did not identify how the facility develops or maintains a plan to maximize recruitment and retention of direct care staff, as required by 10NYCRR S415.26.
Failure to Provide and Document Ordered Wound Care
Penalty
Summary
A deficiency was identified when a resident with multiple comorbidities, including morbid obesity, diabetes mellitus, peripheral vascular disease, and a history of traumatic amputation, did not consistently receive wound care treatments as ordered by the physician. Documentation revealed multiple omissions in the Treatment Administration Record over several weeks, with wound care treatments not completed or not documented on numerous days. The resident's care plan required specific wound care interventions, monitoring, and reporting to the medical provider, but there was no consistent evidence that these interventions were carried out or that refusals were documented and communicated as required by facility policy. Wound assessments showed a progressive worsening of the resident's lower extremity wounds, with measurements indicating significant increases in wound size over time. Despite the resident's intact cognition and the presence of detailed physician orders for wound care, the records lacked documentation of completed treatments and did not reflect any consistent reporting of treatment refusals or changes in wound condition to the nurse practitioner or physician. Interviews with nursing staff and supervisors confirmed that blank areas in the treatment records indicated treatments were not done and that there was a failure to endorse missed treatments to subsequent shifts or notify supervisors as required. Staff interviews further revealed that the resident was considered non-compliant with wound care and other aspects of their treatment plan, but there was no documentation to support this or to show that refusals were communicated to the healthcare provider. The wound care nurse practitioners and supervisors acknowledged a lack of proper documentation and communication regarding wound care treatments, with one nurse practitioner stating that nurses needed re-education on documenting treatments as done or refused. The failure to provide and document wound care as ordered, and to communicate refusals or changes in condition, led to the resident's wounds worsening and ultimately required hospital evaluation.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food safety practice during a recertification survey. Observations made during an initial tour of the kitchen revealed several deficiencies in the storage of food items. In the walk-in freezer, there were open and undated boxes of beef meatballs, precooked fish sticks, veggie burgers, and vegetable patties. Additionally, a bag of frozen pork butt was found without an expiration date, and open bags of hash brown patties and French fries were undated. The Regional Director of Operations acknowledged that once products were opened, they needed to be dated, but this was not done. Further observations in the walk-in refrigerator showed a bulk container with 26 boxes of fat-free lactose-free milk that had expired the day before the inspection. In the dry storage room, a box of lemonade was found with an expiration date from two months prior. Emergency supplies included two jars of maraschino cherries that had expired three months earlier. The Regional Director of Operations admitted to not knowing how these expired products remained on the shelves, indicating a lapse in the facility's adherence to its own food storage policies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure the development and implementation of comprehensive person-centered care plans for several residents, as observed during the recertification and abbreviated surveys. Specifically, Resident #84, who was admitted with diagnoses including hypertension, atrial fibrillation, and heart failure, did not have a care plan in place to address cardiac issues. Despite being on medications such as Metoprolol Tartrate and Apixaban, there was no documented evidence of a cardiac care plan in the electronic medical record. Registered Nurse #9 confirmed the absence of such a plan and stated that the Admission Nurse and Unit Manager were responsible for writing care plans. Resident #122, admitted with diagnoses including urinary tract infection, renal insufficiency, and benign prostatic hyperplasia, also lacked a care plan addressing their urinary tract infection or cystitis. The resident's medical records showed multiple physician orders for antibiotics like Augmentin and Zosyn, yet no care plan was documented. Both Registered Nurse #10 and the Director of Nursing acknowledged the absence of a care plan for the urinary tract infection, noting that the responsibility for care plan development lay with the admitting nurse, Unit Manager, and Nursing Supervisors. Similarly, Resident #179, who was admitted with asthma, obstructive sleep apnea, and anxiety, did not have a care plan for respiratory care and the use of oxygen. The resident was receiving continuous oxygen therapy, as documented in physician orders and nursing progress notes, but there was no care plan in place to address this need. The Director of Nursing stated that care plans should be initiated upon admission and followed up by unit managers and nursing supervisors, highlighting a lapse in the facility's adherence to its care planning procedures.
Failure to Prevent Accidents and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment for residents, resulting in multiple incidents involving three residents. Resident #280, who was at high risk for falls, experienced an unwitnessed fall due to the absence of care plan interventions such as bed and chair alarms. The resident sustained facial lacerations and a subdural hematoma, requiring hospitalization. The facility did not conduct a thorough investigation to assess the adequacy of interventions or adherence to the care plan, as evidenced by discrepancies in incident reporting and lack of documentation of safety checks. Resident #281, with severe cognitive impairment and a history of swallowing difficulties, became unresponsive during dinner and required cardiopulmonary resuscitation. Despite the incident occurring during mealtime, the facility did not investigate whether the resident received the correct food consistency or had adequate supervision. Staff statements and emergency department reports indicated a choking incident, but no incident report or investigation was initiated by the facility. Resident #92, who required a mechanical lift and two-person assistance for transfers, was improperly transferred by a Certified Nurse Aide without the use of a lift or additional staff, resulting in a broken wrist. The aide, from a staffing agency, did not follow the care plan directives, which were available in the facility's electronic health record. The facility's investigation determined neglect due to the direct violation of the care plan, leading to the aide's removal from the facility.
Failure to Complete Annual Performance Appraisals for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months, as required. During the recertification and abbreviated surveys, it was found that there was no documented evidence of annual performance reviews for four out of five Certified Nurse Aides whose records were reviewed. These aides were hired on various dates ranging from 2018 to 2023. The Director of Human Resources was unable to locate the annual performance reviews for these aides and explained that the process involves giving the review forms to the staff member and their supervisor based on the hire date, with the expectation that the forms are completed and returned within a week. However, this process was not followed, leading to the deficiency.
Inadequate Infection Control and Surveillance
Penalty
Summary
The facility failed to properly implement transmission-based precautions for residents with infections, as observed during the recertification and abbreviated surveys. Specifically, three residents were not managed according to the required infection control precautions. For instance, two Certified Nurse Aides were observed not wearing gowns while attending to a resident on Contact Precautions for Vancomycin Resistant Enterococcus and Colostrum Difficile. Additionally, the resident's physician orders did not include Enhanced Barrier or Contact Precautions, which were necessary due to the presence of a urinary catheter and specific bacterial infections. The Infection Preventionist acknowledged that these precautions should have been ordered earlier. Furthermore, the facility did not ensure that residents exposed to or positive for COVID-19 were managed with appropriate precautions. One resident, who was exposed to COVID-19, was seen in the hallway without a mask, contrary to the expected Standard Precautions. Another resident, positive for COVID-19, had a Droplet Precaution sign on their door, but staff were not instructed to wear gowns, indicating a lack of Contact Precautions. The Infection Preventionist admitted that there was a lack of understanding among staff regarding the appropriate precautions and personal protective equipment required. The facility also failed to maintain an effective infection surveillance plan. The infection tracking logs were incomplete, missing entries for several residents with infections. For example, residents with symptoms of urinary tract infections and other conditions were not entered into the tracking log in a timely manner. The Infection Preventionist noted that the logs should be used to track infections and prevent their spread, but acknowledged that the logs were not started until September 2024. The Administrator confirmed that infections should be documented in real-time upon discovery.
Ineffective Pest Control Program Leads to Persistent Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as gnats and cockroaches in Resident #70's room. Observations during the survey revealed insect and rodent traps with pests inside, indicating an ongoing issue. Resident #70 reported regular encounters with flies and roaches over their three-year stay at the facility. The facility's pest logbook from 2022 to 2024 documented the presence of cockroaches in various areas, including dining halls, lounges, and kitchen areas. Interviews with staff, including a CNA and the Director of Housekeeping, confirmed the persistent issue with roaches, particularly in residents' bathrooms and dining areas. The Director of Housekeeping noted that the problem worsened from 2023 to 2024, despite pest control services. The Administrator acknowledged the issue and mentioned switching pest control companies in August 2024 due to ineffective services from the previous provider. The Maintenance Director reported improvements with the new pest control company, although the deficiency persisted during the survey period.
Inaccurate MDS Assessment for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident at the time of assessment. Specifically, the MDS for a resident with a care plan that included bed and chair alarms inaccurately documented that the resident had no alarms. The resident was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, a history of falling, and muscle weakness. The care plan dated 8/2/23 indicated interventions such as placing alarms on both the bed and chair due to the resident being at risk for falls. However, the admission MDS dated 8/5/23 incorrectly noted that the resident had no bed or chair alarms. During an interview, the MDS Coordinator acknowledged that the care plans are reviewed for information but admitted that the alarms were not coded on the MDS as they should have been.
Deficiency in Staff Education on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that staff, specifically Certified Nurse Aide #13, received necessary education on abuse, neglect, exploitation, dementia management, and misappropriation of resident property. This deficiency was identified during a recertification and abbreviated survey. The facility's policy required all employees to receive education on these topics, but there was no documented evidence that Certified Nurse Aide #13 had received such training. This lack of education was highlighted when Resident #92 sustained a wrist fracture, and an investigation determined that neglect had occurred due to a direct care plan violation by Certified Nurse Aide #13. The investigation revealed that Certified Nurse Aide #13 was employed through a staffing agency, and both the facility and the agency failed to provide documentation of the required education. Interviews with the former Director of Nursing and the staffing agency's Account Manager indicated that the responsibility for education was unclear, with the agency suggesting it was up to the aide to pursue training. Certified Nurse Aide #13 claimed to have received education but could not provide documentation. The facility's Administrator confirmed that no in-service training records were available for the aide, and the incident occurred under the previous administration.
Improper Storage of Medications at Resident's Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored according to the manufacturer's specifications and professional standards of practice. During the recertification survey, it was observed that a resident had physician-ordered medications, including an Ipratropium-Albuterol inhaler, Sodium Chloride nasal solution, and Flonase allergy relief nasal spray, on their bedside table. The facility's policy on medication storage requires that drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in this instance. The resident involved had diagnoses including Asthma, Obstructive Sleep Apnea, and Anxiety, and was documented to have intact cognition. Despite this, there was no documented evidence in the care plans addressing the resident's self-administration of medications. Interviews with facility staff, including a Registered Nurse Supervisor and a Licensed Practical Nurse Unit Manager, revealed that medications left at a resident's bedside require a physician's order and an assessment to determine if the resident can self-administer medications safely. The Director of Nursing confirmed that there were no physician's orders or assessments for self-administration for the resident, indicating a lapse in following the facility's medication self-administration policy.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for a resident during the Recertification Survey. Resident #70, who was admitted with diagnoses including non-Alzheimer's dementia, malnutrition, and ataxia, reported that the food was cold and expressed dissatisfaction with the meals. The resident's son confirmed this by stating they had to buy food for the resident. A test tray was requested, and the temperatures of the food items were found to be below acceptable levels, with a hamburger at 82.2 degrees Fahrenheit and cooked green beans at 77.4 degrees Fahrenheit. The cook was unaware of the low temperatures of the food ready to be served. The Regional Director of Operations stated that the food was at acceptable temperatures when it left the kitchen.
Failure to Ensure Resident Access to Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds on weekends, as required by their own policy and federal and state laws. The policy stated that residents should have daily access to their personal needs account, including weekends and holidays. However, the Reception Bank Log records showed inconsistencies, with a beginning balance of 0 on several days, and missing documentation for certain dates. Resident #14, who was reviewed for personal funds, reported that on weekends, the money set aside at the desk was often depleted by evening, and there was no plan in place to replenish funds when they ran out. This issue was highlighted during a Resident Council Facility Task meeting, where Resident #14 expressed concerns about the lack of access to funds and suggested the installation of an ATM. Interviews with facility staff revealed a lack of awareness and communication regarding the issue. The Receptionist stated that the bank box should always have a minimum of $100, but could not explain the discrepancies in the log. The Business Office Manager, who started in May 2024, was responsible for monitoring and replenishing the funds but was unaware of any shortages on weekends. Despite procedures for the receptionist to contact the Business Office Manager if funds were low, the logs still showed days with a 0 balance, indicating a failure in the process. The Social Worker Assistant was also unaware of any issues with residents accessing their funds.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 38 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sullivan County Adult Care Center | 2.2 mi | ★★★★★ | 10 | 1 |
| Roscoe Regional Rehab & Residential H C F | 13.8 mi | ★★★★★ | 28 | 0 |
| Mountainside Residential Care Center | 25 mi | ★★★★★ | 0 | 0 |
| St Josephs Place | 28.8 mi | ★★★★★ | 3 | 0 |
| Highland Rehabilitation And Nursing Center | 29.1 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Achieve Rehab And Nursing Facility.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.