Achieve Rehab And Nursing Facility
Achieve Rehab And Nursing Facility in Liberty, NY — inspection on May 22, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
room.
Juice and milk were being served to residents in disposable plastic cups.
disposable plastic cups were being used.
They stated they were ordering new cups.
They stated
10 New York Code Rules Regulations 415.3(d)(1)(i)
335449 05/22/2026
Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754
but when observed with this surveyor, they stated it would need a protective edge applied.
They
were working to fix the air conditioning issue.
They stated they had repaired the dripping sink in room
handrails needed to be affixed and would make sure that it was completed.
They stated that room [ROOM NUMBER] was one of the oldest rooms so they were not surprised that the wallpaper was peeling up and needed repair.
They stated that they do daily rounding, but more for safety checks not for repairs.
They expected staff to complete a request for maintenance service if something was observed or reported as broken.10 New York Code Regulations Rules 415.3
335449 05/22/2026
Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754
During a telephone interview on 05/20/2026 at 11:45 AM, Psychiatric Nurse Practitioner #2 stated Resident #80 had encephalopathy which caused memory impairment.
They stated that many of their contacts with Resident #80 were appropriate.
They stated after the incident, they asked Resident #80 whether they were hurt and provided emotional support.
They stated that due to memory impairment, Resident #80's account of the incident became confused.
They stated the resident had a blunted effect and did not recall or remember what happened because of the resident's liver disease.
During a follow-up interview on 05/21/2026 at 11:00 AM, Psychiatric Nurse Practitioner #2 stated they came to the facility once a week to see residents.
They stated that the sexual assault, in theory, would have effect on quality of life.
However, it was difficult to assess this in Resident #80 because of dementia with cognitive decline.
They stated Resident #80 minimized their feelings by saying it was okay.
During an interview on 05/20/2026 at 12:55 PM, Social Service Assistant #4 stated they visited Resident # 80 after the sexual abuse incident to provide support and ensure Resident # 80 felt safe in the facility.
Social Service Assistant #4 stated Resident # 80 did not remember the sexual abuse incident. 10 New York Codes Regulations and Rules 415.4(b)(1)(i)
335449 05/22/2026
Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754
will need a shower.
They stated nails and shaves were to be performed on shower days.
They stated
They stated showers and clean hands were important because it makes residents feel good.
They
ensuring care was given. 10 New York Code Rules Regulation 415.12 (a)(3)
335449 05/22/2026
Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754
assistance with activities of daily living.The 08/22/2024 Practitioner Progress Note documented the
adequately evaluate the resident following the fall.
The family reported bruising was present on the
the facility should have recognized the severity of the resident's condition and initiated hospital transfer without requiring family insistence.
During an interview on 05/19/2026 at 6:55 PM, Nurse Practitioner #1 stated Resident #153 did not sustain a head strike during the unwitnessed fall.
Nurse Practitioner #1 stated although Resident #153 was prescribed Eliquis, they were not sent to the hospital after the fall because no head strike was identified.
Nurse Practitioner #1 stated the resident remained at baseline, although ecchymosis and increased behaviors were observed.
Nurse Practitioner #1 further stated the expectation was that Resident #153 would undergo radiographic imaging to rule out fractures.
Nurse Practitioner #1 stated radiographic imaging had been ordered, and the technician was present on 08/22/2024.
Nurse Practitioner #1 further stated the family expressed concern the radiographic imaging had not been completed sooner and asked that the resident be transferred to the hospital.
Nurse Practitioner #1 stated they arranged transfer to the hospital for Resident #153.
During an interview on 05/20/2026 at 11:58 AM, Registered Nurse #3 who assessed Resident #153, stated when the resident was found on the floor it would be considered an unwitnessed fall because no staff observed the fall.
Registered Nurse #3 further stated normal practice included notifying the physician of injuries and whether the resident received anticoagulant medication.
Registered Nurse #3 stated there was no recollection of whether the physician was informed that Resident #153 received anticoagulant medication.
Registered Nurse #3 further stated protocol included neurological checks and safety checks every 30 minutes.
Registered Nurse #3 stated radiological imaging was ordered, and they did not know why imaging had not been done. 10 New York Code Rules Regulations 415.12
335449 05/22/2026
Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754
During observations conducted on 05/17/2026 at 12:15 PM and 05/18/2026 at 9:43 AM, Resident #61 had a coffee maker in the resident's room with supplies; however, the coffee maker lacked an inspection sticker.
During an interview on 05/20/2026 at 12:12 PM, Licensed Practical Nurse #7 stated that Resident #61 did not use the coffee maker.
The nurse explained that family members used the coffee maker during visits; however, the resident could potentially attempt to make coffee.
During an interview on 05/21/2026 at 9:59 AM, Registered Nurse Unit Manager #6 stated that Resident #61 had a coffee maker in the resident room that family members had brought in.
The nurse stated that no assessment had been completed to determine whether the resident could safely operate the coffee maker.
The nurse further stated that Resident #61 had not been observed preparing coffee with the machine; however, there was concern that the resident could attempt to make coffee independently.
During an interview on 05/21/2026 at 10:00 AM, the Director of Nursing stated that the facility did not have a policy or assessment process regarding residents' use of coffee makers.
New York Code Rules Regulations 415.12 (h)(2)
335449 05/22/2026
Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754
12/20/2025 was reviewed and documented magnesium gluconate oral tablet 250 milligrams.
Give 2
to administration.
The medication nurses should not substitute a medication without an order even if
that orders should be checked prior to administration.
The medication nurse should always get an order that reflects what is being administered if a substitute is needed, even if the dose is the same.
They should not make a substitution without an order. 10 NYCRR 415.12(m)(2)
During an interview on 05/21/2026 at 9:27 AM, Licensed Practical Nurse #22 stated that they were distracted and did not provide hand hygiene between Resident #40 and Resident #95 when administering their medications.
They should have sanitized their hands between the two residents
During an interview on 05/21/2026 at 9:37 AM, Registered Unit Manager #6/Interim Infection Preventionist stated that nurses should sanitize their hands between residents when medications are administered.
Community equipment should be wiped down with the available sanitizing wipes between residents.
They also stated that when nurses administer eye drops, a separate tissue should be used for each eye when wiping the eyes after administration.
During an interview on 05/22/2026 at 11:46 AM, the Director of Nursing stated nurses should sanitize their hands between residents when administering medication.
Shared equipment should also be sanitized between residents. 10 New York Code Rules Regulations
335449 05/22/2026
Achieve Rehab and Nursing Facility 170 Lake Street Liberty, NY 12754
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.