Achieve Rehab And Nursing Facility

for residents competently during both day-to-day operations (including nights and weekends) and

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

failed to adequately identify and indicate how they maintain the resources necessary to care for its residents.

Specifically, the facility assessment failed to adequately identify how the facility addresses contingency planning regarding necessary resources and failed to identify a facility plan to maximize recruitment and retention of direct care staff.The facility's assessment dated [DATE], reviewed by Quality Assurance and Performance Improvement Committee on 09/04/2025 is the most recent assessment conducted by the facility, it is the facility assessment that was reviewed as part of the Abbreviated Survey noted above, and which for these findings will be known as the facility assessment.The facility assessment indicates that the facility is a 140 bed Skilled Nursing Facility (SNF) with four (4) nursing units: one rehabilitation unit, one stepdown medically complex unit, and two long term care units housing residents with Dementia and other chronic illnesses.

There is no breakdown showing the bed capacity per unit.The facility's assessment under subheading Staffing Plan states the following: Based on resident census and acuity, staffing is assigned to ensure there are sufficient staff to meet the needs of the residents at any given time.

Staffing is reviewed prior to each shift to account for admissions, trips to medical appointments and acuity. It is the intent to assign the same staff to nursing units in order to maintain continuity of care. In the event there are multiple admissions, additional RNs are scheduled to ensure timely assessment and customer service.The facility assessment does not adequately identify contingency planning for events that do not require the activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.The facility's assessment also does not identify how the facility develops and or maintains a plan to maximize recruitment and retention of direct care staff.10NYCRR S415.26 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

335449 03/30/2026

Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754