Sullivan County Adult Care Center
Sullivan County Adult Care Center in Liberty, NY — inspection on May 29, 2026.
Found 5 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
During an interview on 05/22/2026 at 04:13 PM, the Administrator stated they were not made aware of the allegations of abuse verbal/physical abuse by Certified Nurse Aide #2 against Resident #1 until they were contacted by the Attorney General's office on 05/21/2026.
The Administrator stated statements were collected on 05/11/2026 to address Certified Nurse Aide #1 becoming upset and leaving their shift.
The Administrator stated Certified Nurse Aide #2 continued working in the facility following the allegations and was reassigned to another unit on 05/21/2026.
During a follow-up interview on 05/22/2026 at 03:25 PM, the Administrator stated the alleged incident involving Resident #1 should have been investigated and an Accident and Incident report should have been initiated.
Registered Nurse Supervisor #1 should have completed a body assessment, written a nursing assessment, and initiated an investigation.
Psychiatric/ psychological services should have been made aware of the allegations involving Resident #1.
Staff should not use foul language toward residents as a means of redirection.
During an interview on 05/26/2026 at 02:58 PM, Psychiatrist #1 stated Psychiatrist #1 saw Resident #1 on 05/26/2026 due to the allegations of abuse.
Psychiatrist #1 stated this was the first time they were made aware of the incident.
Psychiatrist #1 stated Resident #1 was very confused and disoriented and was unable to communicate.
Psychiatrist #1 stated they expect to be notified of allegations of abuse so that residents can be evaluated timely.
During an interview on 05/27/2026 at 02:28 PM, the Medical Director stated the Medical Director was made aware of the allegations on 05/21/2026.
The Medical Director stated they expect to be notified right away about incidents of abuse so that the resident can be evaluated timely for harm.
The Medical Director stated when Resident #1 was seen there were no injuries, however, Resident #1 was confused and could not recall the incident. Resident #1 has advanced dementia.
The Medical Director stated arguing in front of residents can cause psychological harm and if that happens, residents should be evaluated. 10 NYCRR 415.4(b)(1)
335628 05/29/2026
Sullivan County Adult Care Center 256 Sunset Lake Road Liberty, NY 12754
Investigation Summary Report must be submitted to NYDOH within 5 business days.Resident #1 was admitted to the facility with diagnoses including, but not limited to, dementia, depression, and anemia.The admission Minimum Data Set (a resident assessment tool) dated 04/11/2026 documented Resident #1 had moderately impaired cognition.
During an interview on 05/21/2026 at 02:08 PM, Certified Nurse Aide #1 stated Resident #1 was near the nurses' station yelling profanities and asking to be toileted while pants were down.
Certified Nurse Aide #1 stated Certified Nurse Aide #2 was yelling the same profanities back to Resident #1, aggressively pushed Resident #1 back into the wheelchair, and later placed Resident #1 in the dining/dayroom area with the wheelchair against the wall and the dining room table positioned against Resident #1, preventing Resident #1 from getting out of the wheelchair.
Certified Nurse Aide #1 stated observations were reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 on 05/11/2026.Review of facility documentation revealed the allegation involving Resident #1, reported on 05/11/2026, was not reported to the New York State Department of Health until 05/21/2026.
During an interview on 05/21/2026 at 04:13 PM and on 05/22/2026 at 03:25 PM, the Administrator stated they were not made aware of the incident involving allegations of abuse involving Certified Nurse Aide #2 allegedly being verbally and physically abusive toward Resident #1 until contacted by the Attorney General's office on 05/21/2026.
The Administrator stated the facility process for reporting is that when the supervisor gets a report, they will call the Director of Nursing and Administrator to inform them and the Administrator or the Director of Nursing will report to the New York State Department of Health.
The Administrator stated the alleged incident of abuse should have been investigated and reported.
During an interview on 05/21/2026 at 05:10 PM, Registered Nurse Supervisor #1 stated Certified Nurse Aide #1 reported allegations of verbal and physical abuse to them on 05/11/2026.
Registered Nurse Supervisor #1 stated the Director of Nursing was notified on 05/11/2026.
During an interview on 05/21/2026 at 05:31 PM, the Director of Nursing stated office staff who are mandated reporters know they are required to report allegations of abuse and staff are left with instructions regarding reporting requirements.
The Director of Nursing stated the allegations were not reported to the New York State
335628 05/29/2026
Sullivan County Adult Care Center 256 Sunset Lake Road Liberty, NY 12754
notified of the allegations involving Resident #1.
The Administrator stated staff should not use foul
jeopardy to resident health or called on 05/26/2026.
The Facility submitted a removal plan to remove the immediacy on safety 05/11/2026.
The facility implemented the following to remove immediacyAn investigation was initiated and reported to New York State Department of HealthResident #1 was assessed, and
interviews were conducted.
Facility provided in-service attendance and lesson plan provided to facility staff at 99%.The facility will implement a tracking system for abuse/neglect/allegation/investigation to audit all accident/incident reports Interviews were conducted with registered nurses, the Assistant Director of Nursing, the Director of Nursing, the Director of Rehab, licensed practical nurses who confirmed receiving inservice on initiating investigation and abuse.
The facility's policy and procedure titled Abuse, Identification and Reporting were reviewed and no changes were made.IJ was removed on 05/28/2026 at 4:57 PM.
335628 05/29/2026
Sullivan County Adult Care Center 256 Sunset Lake Road Liberty, NY 12754
During an interview on 05/29/2026 at 02:57 PM, Registered Nurse #3 stated they were the Unit Manager on Unit 2 and assisted on Units 3 and 4 as needed.
Registered Nurse #3 stated they were not aware of the 05/11/2026 allegations of verbal and physical abuse involving Resident #1 and were not made aware of the allegations until staff received education regarding abuse and reporting requirements.
Registered Nurse #3 stated they were not aware of the specific details of the allegations.
Registered nurses review, update, and revise resident care plans.
Care plans are updated to reflect residents' current needs, changes in condition, and new incidents, including Accident and Incident reports.
Part of the Accident and Incident process includes reviewing and updating the resident's care plan and notifying the resident's family.
Registered Nurse #3 stated care plans are reviewed and revised to ensure they accurately reflect the resident's current needs and plan of care. 10 NYCRR 415.11(c)(1)
335628 05/29/2026
Sullivan County Adult Care Center 256 Sunset Lake Road Liberty, NY 12754
Staff Educator and ensuring staff received required training.
The Director of Nursing stated staff are
orientation and training before caring for residents.
The Director of Nursing stated staff who have not
training provides staff with the knowledge and skills necessary to care for residents. 10 NYCRR 415.13(c)
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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.