D+
50/100Sullivan County Adult Care Center Inspection Report, Violations & Safety Grade (Liberty, New York)
256 Sunset Lake Road, Liberty, New York 12754
Phone: 8452928640
CMS Overall:1/5
Overview & Bed Count
Certified Beds
146
Avg Residents/Day
103.9
Ownership
Government - County
Provider Type
Medicare and Medicaid
County
Sullivan
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | New York Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.64 | 0.73 | -0.08 |
| Total Nurse Hours per Resident per Day | 4.20 | 3.69 | +0.51 |
| CMS Staffing Rating | 3/5 | 2.9/5 | - |
| Nursing Staff Turnover | 64.5% | 40.3% | - |
Health Citation History
44 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-25 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2026-08-25 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2026-08-25 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2026-05-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | J – Immediate Jeopardy |
| 2026-05-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2026-05-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-05-29 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2026-05-29 | Nursing and Physician Services Deficiencies | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | D – Moderate Harm Potential |
| 2026-02-02 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | H – Actual Harm |
| 2026-02-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E – Moderate Harm Potential |
| 2026-02-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | E – Moderate Harm Potential |
| 2025-12-02 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-11-20 | Nursing and Physician Services Deficiencies | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | D – Moderate Harm Potential |
| 2025-04-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-04-15 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-04-15 | Quality of Life and Care Deficiencies | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | D – Moderate Harm Potential |
| 2024-09-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2024-09-27 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-09-27 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2024-09-27 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2024-09-27 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2024-09-27 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2024-09-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-09-27 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-09-27 | Nursing and Physician Services Deficiencies | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | D – Moderate Harm Potential |
| 2023-10-18 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2023-01-05 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2023-01-05 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2023-01-05 | Resident Rights Deficiencies | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D – Moderate Harm Potential |
| 2023-01-05 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-01-05 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2023-01-05 | Nutrition and Dietary Deficiencies | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | D – Moderate Harm Potential |
| 2023-01-05 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2023-01-05 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2023-01-05 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2023-01-05 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2019-09-04 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2019-09-04 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2019-09-04 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2019-09-04 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2019-09-04 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2019-09-04 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2019-09-04 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2019-09-04 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
Fire Safety Citation History
32 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-09-27 | Construction Deficiencies | Use approved construction type or materials. | E – Moderate Harm Potential |
| 2024-09-27 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2024-09-27 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-09-27 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2024-09-27 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | E – Moderate Harm Potential |
| 2024-09-27 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2024-09-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2024-09-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | E – Moderate Harm Potential |
| 2024-09-27 | Egress Deficiencies | Install proper backup exit lighting. | D – Moderate Harm Potential |
| 2024-09-27 | Smoke Deficiencies | Install an approved automatic sprinkler system. | D – Moderate Harm Potential |
| 2024-09-27 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D – Moderate Harm Potential |
| 2024-09-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2023-01-05 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2023-01-05 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2023-01-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2023-01-05 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-01-05 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2023-01-05 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | C – Minimal Harm Potential |
| 2023-01-05 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | C – Minimal Harm Potential |
| 2019-09-04 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2019-09-04 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2019-09-04 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2019-09-04 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2019-09-04 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | E – Moderate Harm Potential |
| 2019-09-04 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2019-09-04 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2019-09-04 | Electrical Deficiencies | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | D – Moderate Harm Potential |
| 2019-09-04 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | C – Minimal Harm Potential |
| 2019-09-04 | Emergency Preparedness Deficiencies | Provide a means of sharing information on occupancy/needs. | C – Minimal Harm Potential |
| 2019-09-04 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | C – Minimal Harm Potential |
| 2019-09-04 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | C – Minimal Harm Potential |
| 2019-09-04 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | C – Minimal Harm Potential |
Total Penalties & Fines
$9,620
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-09-27 | Fine | $9,620 | - |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Liberty area at no cost.
Find Safe, Vetted Facilities Near Liberty
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.