Cycle 1
Health 2024-09-27 · Fire 2024-09-27
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Liberty, NY
Sullivan County Adult Care Center
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
Facility snapshot
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
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing
LPN hours / resident day
0.98
Licensed practical nurse staffing
Aide hours / resident day
2.61
Nurse aide staffing
Weekend hours
3.57
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-05 · Fire 2023-01-05
10 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-09-04 · Fire 2019-09-04
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-09-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-09-27
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-09-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-09-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-09-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-13
D · Potential for more than minimal harm
2024-09-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-09-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-09
E · Potential for more than minimal harm
2023-01-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-05
E · Potential for more than minimal harm
2023-01-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-05
E · Potential for more than minimal harm
2023-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-05
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 2023-03-05
D · Potential for more than minimal harm
2023-01-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-05
C · Minimal harm
2023-01-05
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-03-05
C · Minimal harm
2023-01-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-05
E · Potential for more than minimal harm
2019-09-04
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-04
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 2019-10-24
E · Potential for more than minimal harm
2019-09-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-04
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2019-10-24
C · Minimal harm
2019-09-04
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2019-10-24
C · Minimal harm
2019-09-04
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-10-24
C · Minimal harm
2019-09-04
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-10-24
C · Minimal harm
2019-09-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-24
C · Minimal harm
2019-09-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-10-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
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 2026-01-31
D · Potential for more than minimal harm
2025-11-20
F841 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2025-04-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-04-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-04-15
F741 · Quality of Life and Care Deficiencies
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
G · Actual harm
2024-09-27
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 2024-11-22
F · Potential for more than minimal harm
2024-09-27
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 2024-11-22
E · Potential for more than minimal harm
2024-09-27
F725 · Nursing and Physician Services Deficiencies
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
E · Potential for more than minimal harm
2024-09-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-09-27
F561 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-09-27
F584 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-09-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-09-27
F711 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2023-10-18
F580 · Resident Rights Deficiencies
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
J · Immediate jeopardy
2023-07-07
F678 · Quality of Life and Care Deficiencies
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
E · Potential for more than minimal harm
2023-01-05
F725 · Nursing and Physician Services Deficiencies
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
D · Potential for more than minimal harm
2023-01-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-05
F625 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2023-01-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-05
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 2023-03-05
D · Potential for more than minimal harm
2023-01-05
F801 · Nutrition and Dietary Deficiencies
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
D · Potential for more than minimal harm
2023-01-05
F806 · Nutrition and Dietary Deficiencies
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
D · Potential for more than minimal harm
2023-01-05
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 2023-03-05
D · Potential for more than minimal harm
2023-01-05
F842 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-05
D · Potential for more than minimal harm
2019-09-04
F578 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2019-09-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
D · Potential for more than minimal harm
2019-09-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-04
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 2019-11-01
D · Potential for more than minimal harm
2019-09-04
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 2019-11-01
D · Potential for more than minimal harm
2019-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-04
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 2019-11-01
Penalties and ownership
What sits behind the stars
$9,620
2024-09-27
Fine
Fine · fine $9,620
Fine
$22,340
2023-07-07
Fine
Fine · fine $22,340
Fine
Ownership
Buck, Nancy
Operational/Managerial Control · Individual
County Of Sullivan
Operational/Managerial Control · Organization
Holton, Megan
Operational/Managerial Control · Individual
Patel, Deepesh
Operational/Managerial Control · Individual
Sunset Lake Consulting LLC
Operational/Managerial Control · Organization
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#3
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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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