LIBERTY – The New York State Department of Health (DOH) completed a facility survey of the Adult Care Center (ACC) at Sunset Lake in Liberty from Sunday, September 22 through Friday, September 27, the first such survey since last January. The completion of the survey revealed nine deficiencies, with the Care Center receiving the Statement of Deficiencies on Friday, October 11, according to the facilities’ latest report. 

Deputy Administrator of the ACC, Bobbi-Ann Kanoff, reported to the Sullivan County Legislature last week that a Plan of Correction was submitted timely after reception of the Statement of Deficiencies, and they are awaiting the survey team’s response to that Plan of Correction.

Kanoff noted in the report, that the nine deficiencies are less than were found in the last survey from 2023 (11) and the one before that in 2019 (12). However, it is still higher than the New York State average for survey deficiencies (6.2), but it is lower than the national average (9.6). 

“While this is an improvement, star rating since the Imminent Jeopardy citation from the last cycle [2023] will continue to hold weight until the summer of 2025 at the earliest,” Kanoff said. “Hopefully if we get the survey on time next year, then it will not be so weighted and we may see an improvement in star rating. But with it still in the most recent survey cycle, it will still hold a heavy weight until at least that time.”

The nine deficiencies are as follows:

483.10 Resident Rights, Self Determination

483.10 Resident Rights, Safe/Clean/Comfortable/Homelike Environment

483.12 Freedom from Abuse, Neglect and Exploitation 

483.25 Quality of Care, Free of Accident Hazards

483.25 Quality of Care, Respiratory

483.30 Physician Services 

483.35 Nursing Services, Sufficient Nursing Staff - Repeat

483.60 Food and Nutrition Services, Nutritive Value/Appear, Palatable/Prefer Temp

483.60 Food and Nutrition Services, Food Procurement, Store/Prepare/Serve-Sanitary 

The Imminent Jeopardy citation that Kanoff was referring to in the report was a resident dying at the facility due to the Care Center failing to follow through on the patient’s health care plan, which was investigated by the DOH last year. The investigation revealed the ACC personnel failed to initiate CPR on the patient, leading to their death. The Legislature paid a civil settlement of $32,000 to the DOH following the investigation last year - a $10,000 fine and a one-time payment of $22,000 to the Centers for Medicare & Medicaid Services (CMS). 

The 35-page report goes into detail about what led to each of the deficiencies being cited as well as the facility’s plan of correction for each. The full report will be available to be reviewed by the public on the Centers for Medicare & Medicaid Services (CMS) website (CMS.gov) at Nursing Home Care Compare, once it gets posted there by the DOH. The previous reports from 2023, 2019 and 2017 are all available to review on that website. 

A source close to the situation told the Democrat that it is possible that the County would face a fine due to repeat deficiencies from the 2023 report. Comparing the latest report from the one completed last year, 483.10 Resident Rights, Safe/Clean/Comfortable/Homelike Environment; 483.35 Nursing Services, Sufficient Nursing Staff; and 483.60 Food and Nutrition Services, Food Procurement, Store/Prepare/Serve-Sanitary are all repeat deficiencies. 

District 5 Legislator Cat Scott, Chair of the Health and Human Services Committee, said a few things on the survey report that bothered her while reviewing it. She stated that it seems that there is a lack of accountability and people pointing the finger at someone else. 

According to Lou Setren, President of the Family Council at the ACC, there have also been several family members who have transferred their loved ones from the Care Center to other facilities in the area, including Roscoe Regional Rehab & Residential Health Care Facility - a five-star facility and Achieve Rehab and Nursing Facility in Liberty - a three-star facility. 

“If they can do it, why can’t Infinite Care do it?” Setren pondered. 

Infinite Care is the current operator of the facility, which they have been since signing a consultancy agreement with the county in 2020. Setren stated that he believes the facility was better managed before the consultatory agreement with Infinite Care. 

“My hope is that the consultancy agreement will fall to the wayside and the county takes back the operation of the facility,” Setren said. 

He also said that there is an Infinite Care-operated facility in Ulster County - Golden Hill Nursing and Rehabilitation Center - that is run well and is a good facility. According to Nursing Home Care Compare on Medicare.gov, that facility is currently rated with four stars, including three stars for its health inspections rating as of the latest DOH report in April.