14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
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
256 Sunset Lake Road, Liberty, NY
(845) 292-8640
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
146
Certified beds
Average residents
124
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-04-11
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
RN hours / resident day
0.49
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
9,840
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.17% · Performance 21.55% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.27
Baseline 6.03% · Performance 6.86% · Measure score 3.27 · Achievement 3.27 · Improvement 0
Total nurse turnover
2.74
Baseline 42.86% · Performance 52.48% · Measure score 2.74 · Achievement 2.74 · Improvement 0
Adjusted total nurse staffing
2.93
Baseline 3.60 hours · Performance 3.91 hours · Measure score 2.93 · Achievement 2.93 · Improvement 0.93
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.99% |
10.72%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 17.75% · Lower 95% interval 10.53% |
| Discharge to community | 36.55% |
50.57%
14 pts worse
|
Worse than the National Rate · Eligible stays 156 · Observed rate 29.49% · Lower 95% interval 29.97% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.38% |
95.27%
3.9 pts worse
|
Numerator 106 · Denominator 116 |
| Falls with major injury | 0.86% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 116 |
| Discharge self-care score | 44.19% |
53.69%
9.5 pts worse
|
Numerator 38 · Denominator 86 |
| Discharge mobility score | 59.3% |
50.94%
8.4 pts better
|
Numerator 51 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 5.17% |
2.29%
2.9 pts worse
|
Numerator 6 · Denominator 116 · Adjusted rate 4.81% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 6.12% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 1.22% |
8.2%
7 pts worse
|
Numerator 2 · Denominator 164 |
| Staff flu vaccination coverage | 45.36% |
42%
3.4 pts better
|
Numerator 88 · Denominator 194 |
| Discharge function score | 52.33% |
56.45%
4.1 pts worse
|
Numerator 45 · Denominator 86 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.67% |
25.2%
22.5 pts worse
|
Numerator 2 · Denominator 75 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.0% |
91.2%
6.2 pts worse
|
93.4%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 85.8% · Q3 81.0% · Q4 76.7% · 4Q avg 85.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.4% |
95.3%
8.9 pts worse
|
95.5%
9.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.0%
2.1 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.5% · Q3 5.2% · Q4 5.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.9% |
18.5%
2.6 pts better
|
11.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 9.0% · Q3 27.4% · Q4 23.1% · 4Q avg 15.9% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
6.1%
1.5 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 2.8% · Q3 4.1% · Q4 4.8% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
13.5%
14.1 pts worse
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 25.9% · Q3 23.3% · Q4 29.4% · 4Q avg 27.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
14.8%
5.5 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 8.9% · Q3 8.0% · Q4 11.1% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.6% |
15.1%
3.5 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 21.2% · Q3 11.7% · Q4 4.9% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
15.5%
2.2 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 17.2% · Q3 11.2% · Q4 7.2% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.4%
0.9 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
20.8%
4.5 pts better
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 16.4% · Q3 12.6% · Q4 18.3% · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
6.9%
0.3 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 5.0% · Q3 7.4% · Q4 6.1% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.4% |
76.7%
45.3 pts worse
|
81.7%
50.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.8% · Q2 34.1% · Q3 30.4% · Q4 18.8% · 4Q avg 31.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.7%
3.7 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.1% |
78.8%
44.7 pts worse
|
79.7%
45.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
20.6%
1.2 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 21.2% · Expected 26.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-09
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-09
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-09
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-09
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-04
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-09
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-05
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 2023-03-05
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-05
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-03-05
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-05
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-10-24
Fire Safety
Install proper backup exit lighting.
Corrected 2019-10-24
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 2019-10-24
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-24
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-10-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-10-24
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2019-10-24
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2019-10-24
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-10-24
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-10-24
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-24
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-10-24
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-31
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2026-01-31
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-13
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-13
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-06-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-22
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-22
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-22
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-22
Health
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.
Corrected 2024-11-22
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-22
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-11-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-18
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-07-04
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-05
Health
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.
Corrected 2023-03-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-05
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 2023-03-05
Health
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.
Corrected 2023-03-05
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-03-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-05
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-03-05
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-05
Health
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.
Corrected 2019-11-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-11-01
Health
Respond appropriately to all alleged violations.
Corrected 2019-11-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-11-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-01
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-11-01
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 2019-11-01
Penalties and ownership
Fine · fine $9,620
Fine
Fine · fine $22,340
Fine
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
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