Achieve Rehab: Infection Control Failures Found - NY
The nurse, identified in inspection records only as Licensed Practical Nurse #14, acknowledged on the spot that she should have wiped down the shared glucometer before carrying it to Resident #124. She had just used it minutes earlier on Resident #65. The inspector stopped her at 12:07 p.m. on May 19. She said she would sanitize it now.
That moment was one of three infection control failures inspectors documented during a complaint inspection at the Sullivan County facility this spring, each one caught in real time, each one acknowledged by the nurse involved.
Two days later, on the morning of May 21, inspectors watched Licensed Practical Nurse #22 finish administering medications to one resident, then move directly to preparing medications for a second resident, Resident #95, without sanitizing her hands. Thirteen minutes passed between the end of care for the first resident and the start of care for the second. No hand hygiene in between.
When inspectors spoke with her at 9:27 a.m., she said she had been distracted. She knew she should have sanitized between residents. She said so herself.
The third incident involved eye drops. Licensed Practical Nurse #7 administered dorzolamide, a glaucoma medication, to Resident #157, then used the same tissue to wipe both eyes after the drops were applied. The concern is straightforward: using a single tissue across both eyes risks transferring whatever is in one eye directly into the other.
The Registered Unit Manager, who also served as the facility's interim infection preventionist, confirmed all three practices were wrong. Nurses should sanitize hands between residents during medication rounds. Shared equipment should be wiped with sanitizing wipes between uses. Eye drop administration requires a separate tissue for each eye. The Director of Nursing said the same thing when inspectors interviewed her the following day.
None of this was disputed. The facility's own leadership described the correct procedures. The nurses described the correct procedures. The failures happened anyway.
Then there was the water.
Inspectors reviewed the facility's Legionella logs on May 20 at 11:10 in the morning. Legionella is the bacterium that causes Legionnaires' disease, a severe form of pneumonia that spreads through contaminated water systems, the kind found in large buildings with cooling towers, hot tubs, and complex plumbing. Nursing homes are required to maintain written water management plans specifically to reduce that risk.
Achieve Rehab did not have one. Or if it did, nobody could find it.
The Director of Maintenance told inspectors that afternoon that the Legionella water management plan could not be located. Not that it was being updated, not that it was filed elsewhere. It could not be located.
A water management plan is not a formality. It is a documented, facility-specific set of protocols for monitoring and controlling water temperature, disinfectant levels, and other conditions that allow Legionella to grow. Without it, there is no way to verify the facility has been following any consistent approach to keeping its water supply safe.
Inspectors rated the overall deficiency as causing minimal harm or potential for actual harm. That classification reflects the regulatory framework's assessment of what was documented, not a guarantee that no harm occurred before inspectors arrived.
What the inspection captured was a single day's observation window. The nurse with the glucometer was stopped before she reached the second resident's room. The nurse who skipped hand hygiene between residents was identified after the fact. The eye drop incident was observed but not interrupted. The missing water plan had no timeline attached to how long it had been missing.
The Registered Unit Manager, serving simultaneously as interim infection preventionist, described the correct standards clearly and completely when asked. That role, infection preventionist, exists specifically to catch and correct the kind of lapses inspectors found. The inspection does not say when the interim designation began, or who held the position before.
Achieve Rehab and Nursing Facility sits on Lake Street in Liberty, a small city in the Catskills about 90 miles northwest of New York City. The May 22 inspection was a complaint survey.
The Director of Maintenance could not find the water management plan. Inspectors left without one being produced.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Achieve Rehab and Nursing Facility from 2026-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 31, 2026 · Our methodology
Achieve Rehab And Nursing Facility in Liberty, NY was cited for violations during a health inspection on May 22, 2026.
She had just used it minutes earlier on Resident #65.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.