Cycle 1
Health 2024-10-23 · Fire 2024-10-23
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Liberty, NY
Achieve Rehab And Nursing Facility
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
170 Lake Street, Liberty, NY
(845) 292-4200
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
131
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-06-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,617
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.82
Baseline 18.74% · Performance 19.66% · Measure score 3.82 · Achievement 3.82 · Improvement 0
Healthcare-associated infections
4.07
Baseline 9.14% · Performance 7.25% · Measure score 4.07 · Achievement 1.97 · Improvement 4.07
Total nurse turnover
5.01
Baseline 48.78% · Performance 43.20% · Measure score 5.01 · Achievement 5.01 · Improvement 1.83
Adjusted total nurse staffing
0
Baseline 3.29 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 288 · Observed rate 11.11% · Lower 95% interval 8.15% |
| Discharge to community | 42.47% |
50.57%
8.1 pts worse
|
Worse than the National Rate · Eligible stays 318 · Observed rate 34.59% · Lower 95% interval 37.46% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.59% |
95.27%
4.3 pts better
|
Numerator 245 · Denominator 246 |
| Falls with major injury | 0.41% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 246 |
| Discharge self-care score | 45.77% |
53.69%
7.9 pts worse
|
Numerator 65 · Denominator 142 |
| Discharge mobility score | 53.52% |
50.94%
2.6 pts better
|
Numerator 76 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 4.07% |
2.29%
1.8 pts worse
|
Numerator 10 · Denominator 246 · Adjusted rate 3.14% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 208 · Observed rate 8.17% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 5.21% |
8.2%
3 pts worse
|
Numerator 11 · Denominator 211 |
| Staff flu vaccination coverage | 74.19% |
42%
32.2 pts better
|
Numerator 161 · Denominator 217 |
| Discharge function score | 52.11% |
56.45%
4.3 pts worse
|
Numerator 74 · Denominator 142 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 100 · Denominator 100 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 62 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 35.71% |
25.2%
10.5 pts better
|
Numerator 40 · Denominator 112 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.5 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.3
1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.8 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
91.2%
6.2 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.8% · Q3 97.4% · Q4 96.5% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.3%
About the same
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.0%
2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.1% · Q3 4.3% · Q4 5.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.3% |
18.5%
9.2 pts better
|
11.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.1% · Q3 10.3% · Q4 12.8% · 4Q avg 9.3% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.1%
2 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 6.6% · Q3 9.3% · Q4 7.5% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
13.5%
1.9 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 12.7% · Q3 9.6% · Q4 8.7% · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
14.8%
2.4 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 17.5% · Q3 18.2% · Q4 16.1% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.9% |
15.1%
10.2 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.8% · Q3 4.6% · Q4 4.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
15.5%
3.3 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 15.1% · Q3 5.7% · Q4 6.9% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.4%
0.7 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.9% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
20.8%
7.1 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 11.9% · Q3 11.0% · Q4 9.2% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.9%
0.6 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.6% · Q3 9.3% · Q4 5.7% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.9% |
76.7%
6.8 pts worse
|
81.7%
11.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.9% · Q2 73.2% · Q3 73.1% · Q4 65.0% · 4Q avg 69.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
9.7%
4.6 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 15.0% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.1% |
78.8%
9.7 pts worse
|
79.7%
10.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
20.6%
0.3 pts worse
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 25.5% · Expected 29.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-27 · Fire 2022-09-27
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-03-28 · Fire 2019-03-28
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-23
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-10-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-27
E · Potential for more than minimal harm
2022-09-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-09-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-09-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-09-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-09-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-25
C · Minimal harm
2022-09-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-11-25
C · Minimal harm
2022-09-27
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-11-25
E · Potential for more than minimal harm
2019-03-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-05-23
E · Potential for more than minimal harm
2019-03-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-05-23
B · Minimal harm
2019-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-14
E · Potential for more than minimal harm
2024-10-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-23
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-23
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-23
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-23
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-12-20
D · Potential for more than minimal harm
2023-10-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-08
D · Potential for more than minimal harm
2022-09-27
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-10-24
D · Potential for more than minimal harm
2019-03-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-03-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-03-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-03-28
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-03-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-05-24
Penalties and ownership
What sits behind the stars
Ownership
Ostreicher, Sandra
5% Or Greater Direct Ownership Interest · Individual
Scheiner, Eliezer
5% Or Greater Direct Ownership Interest · Individual
Zelman, Eliezer
5% Or Greater Direct Ownership Interest · Individual
Wood, Ryan
Operational/Managerial Control · Individual
Younesi, Peyman
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sullivan County Adult Care Center
Liberty, NY
1-star overall rating with 1-star inspections with $31,960 in total fines with 14 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Roscoe Regional Rehab & Residential H C F
Roscoe, NY
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Mountainside Residential Care Center
Margaretville, NY
2-star overall rating with 2-star inspections with $8,512 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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