Inspection Reports for
Putnam Nursing & Rehabilitation Center
404 Ludingtonville Road, Holmes, NY, 12531
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 7, 2025
Visit Reason
One isolated Level 3 deficiency related to accident hazards and supervision was found and corrected.
Findings
One isolated Level 3 deficiency related to accident hazards and supervision was found and corrected.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 7, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with care plan implementation and accident prevention after incidents involving Resident #2 who sustained injuries from falls and inadequate supervision.
Findings
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision for Resident #2, who required two-person assist. Two separate incidents occurred where staff did not follow care plan interventions, resulting in serious injuries and eventual death of the resident due to blunt force trauma.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents for Resident #2 who required two-person assist. Staff moved the resident alone using a Hoyer lift and provided care without required assistance, resulting in serious injury and death.
Report Facts
Residents affected: 3
Staff involved: 2
Neuro checks duration: 72
Staff removed from duty: 1
Certified Nurse Aids on duty: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Involved in moving resident alone with Hoyer lift, interviewed about incident | |
| Certified Nurse Aide #4 | Provided care alone, resident bumped head on bedside table, did not ask for help | |
| Registered Nurse Supervisor #1 | Assessed resident post fall, interviewed about incidents | |
| Director of Nursing | Interviewed regarding staff actions and care plan adherence | |
| Medical Examiner #1 | Performed autopsy, stated injuries inconsistent with explanations | |
| Medical Director | Current Medical Director | Commented on incident reporting and staff actions |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Apr 4, 2025
Visit Reason
The inspection was a recertification survey conducted from 3/30/2025 to 4/4/2025 to assess compliance with regulatory requirements for Putnam Nursing & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including environmental cleanliness and maintenance, incomplete and inadequate care plans for residents with contractures and positioning needs, failure to provide necessary personal care such as nail trimming, improper use and documentation of positioning devices, lack of registered nurse coverage for required hours, food safety violations in storage and staff hygiene, incomplete use of infection control precautions, and deficiencies in Quality Assurance committee participation.
Deficiencies (8)
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment with issues such as broken handrails, pervasive urine odor, broken furniture, stained walls, soiled privacy curtains, and dirty baseboards on multiple floors.
F 0656: The facility did not develop or implement comprehensive, person-centered care plans for residents #16 and #60 related to contracture and wheelchair positioning.
F 0677: Resident #16, dependent on staff for personal hygiene, was observed with long, stained fingernails and a left-hand contracture without adequate care or nail trimming.
F 0684: Residents #16, #60, and #37 did not receive appropriate treatment and care according to professional standards, including lack of positioning devices for contractures, improper wheelchair positioning, and failure to use ordered heel boots.
F 0727: The facility failed to ensure a Registered Nurse was on duty for at least 8 consecutive hours on 11/2/2024 as required by regulation.
F 0812: Food was stored without proper identification and dating in kitchen refrigerators, freezers, and pantries; staff failed to wear hairnets and beard covers properly; and kitchen areas had broken tiles, damaged baseboards, and dirt/dust accumulation.
F 0868: The Quality Assurance and Performance Improvement committee lacked required attendance by the Medical Director or designee and the Infection Control Practitioner for multiple quarterly meetings.
F 0880: Housekeeping staff failed to wear appropriate Personal Protective Equipment, including N-95 masks, when entering rooms with Droplet Precautions, and did not properly doff gloves or perform hand hygiene.
Report Facts
Weekend days without RN coverage: 1
Quarterly meetings missing Medical Director attendance: 3
Quarterly meetings missing Infection Control Practitioner attendance: 2
Treatment Administration Record missing signatures: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #5 | Named in observation and interview regarding Resident #16's left hand contracture and nail care. | |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Named in observation and interview regarding Resident #16's contracture care plan and nail care. |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Named in interview regarding Resident #60's wheelchair positioning and Resident #37's heel boots. |
| Certified Nurse Aide #9 | Named in interview regarding Resident #60's wheelchair positioning and Resident #37's heel boots. | |
| Registered Nurse Unit Manager #3 | Registered Nurse Unit Manager | Named in interviews regarding Resident #60's wheelchair positioning and Resident #37's heel boots. |
| Director of Rehabilitation | Named in interviews regarding Resident #60's wheelchair positioning and education. | |
| Director of Nursing | Named in interviews regarding Resident #60's wheelchair positioning and RN staffing. | |
| Director of Housekeeping | Named in interview regarding environmental cleanliness and housekeeping practices. | |
| Director of Maintenance | Named in interview regarding maintenance issues such as broken handrails and furniture. | |
| Food Service Worker #1 | Named in observations and interviews regarding food storage and labeling. | |
| Food Service Worker #2 | Named in observations regarding improper beard net use. | |
| Food Service Worker #3 | Named in observations regarding improper hairnet use. | |
| Maintenance Worker #1 | Named in interview regarding failure to wear hairnet in kitchen. | |
| Housekeeper #1 | Named in observations and interviews regarding improper PPE use in Droplet Precaution room. | |
| Housekeeper #2 | Named in observations and interviews regarding improper mask use in Droplet Precaution room. | |
| Activities and Housekeeping Supervisor | Named in interview regarding housekeeping staff PPE compliance. | |
| Director of Human Resources/Covering Staffing Coordinator | Named in interview regarding RN staffing deficiency. | |
| Administrator | Named in interviews regarding Quality Assurance committee attendance and infection control observations. | |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Named in interview and observation regarding Resident #16's contracture and care plan. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Apr 4, 2025
Visit Reason
Multiple isolated and patterned Level 2 deficiencies related to ADL care, care planning, food sanitation, infection control, quality assurance, quality of care, RN coverage, and environment were found and corrected.
Findings
Multiple isolated and patterned Level 2 deficiencies related to ADL care, care planning, food sanitation, infection control, quality assurance, quality of care, RN coverage, and environment were found and corrected.
Deficiencies (11)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Qaa committee
Quality of care
Rn 8 hrs/7 days/wk, full time don
Safe/clean/comfortable/homelike environment
Building construction type and height
Corridor - doors
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
One isolated Level 4 deficiency for abuse and neglect with substandard quality of care was found and corrected.
Findings
One isolated Level 4 deficiency for abuse and neglect with substandard quality of care was found and corrected.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
The visit was an abbreviated survey conducted to investigate allegations of abuse involving a resident at the facility.
Complaint Details
The investigation was complaint-related, triggered by reports and video evidence of abuse by Licensed Practical Nurse #1 against Resident #1. The complaint was substantiated with video surveillance and staff interviews confirming the abuse. Immediate Jeopardy was identified on 02/26/2025 and the facility returned to compliance on 02/27/2025.
Findings
The facility failed to ensure a resident was free from abuse by a Licensed Practical Nurse who was observed abusing the resident during medication administration. Immediate Jeopardy was identified but the facility returned to compliance the following day after corrective actions including suspension and termination of involved staff.
Deficiencies (1)
F 0600: The facility did not protect a resident from all types of abuse including physical abuse by a Licensed Practical Nurse who forcefully tilted the resident's head back, held their nose, shoved medication into their mouth, kicked the resident's wheelchair, and pushed the wheelchair against a table and wall. Immediate Jeopardy was identified but no actual harm resulted.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Date of abuse incident: Feb 26, 2025
Date facility returned to compliance: Feb 27, 2025
Date of staff termination: Feb 28, 2025
Date of abuse care plan initiation: Nov 23, 2024
Date abuse care plan updated: Feb 28, 2025
Date 1:1 monitoring started: Feb 27, 2025
Date of Resident Council meeting: Mar 4, 2025
Date of Resident Council president interview: Mar 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named as the staff member who abused Resident #1 and was terminated | |
| Certified Nurse Aide #1 | Witnessed abuse and provided statements about the incident | |
| Certified Nurse Aide #2 | Witnessed abuse and reported it to Licensed Practical Nurse #2 | |
| Licensed Practical Nurse #2 | Received report of abuse from Certified Nurse Aide #2 | |
| Director of Nursing | Notified of abuse, initiated investigation, and contacted family | |
| Director of Human Resources | Called local law enforcement and managed staff suspension |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 5, 2023
Visit Reason
One isolated Level 2 deficiency related to quality of care was found and corrected.
Findings
One isolated Level 2 deficiency related to quality of care was found and corrected.
Deficiencies (1)
Quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 5, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care related to treatment and management of residents, specifically focusing on Resident #1's care for frequent recurrent urinary tract infections.
Findings
The facility failed to provide appropriate care for Resident #1 with recurrent urinary tract infections, including incorrect transcription of a physician's order for a kidney urethra bladder (KUB) scan, failure to order a recommended urology consult, and a missed gynecology appointment due to transportation issues. Resident #1 was hospitalized with sepsis secondary to UTI.
Deficiencies (1)
F 0684: The facility did not ensure Resident #1 received appropriate treatment and care according to physician orders and professional standards. The KUB scan order was transcribed incorrectly, the nurse practitioner's recommended urology consult was never ordered, and a scheduled gynecology consult was missed due to transportation failure.
Report Facts
Dates of key events: Physician order for KUB scan dated 10/14/2022; nurse practitioner notes from 11/2/22 and 11/9/22; antibiotic treatments started 11/15/22, 12/14/22, and 12/31/22; gynecology appointment scheduled 1/19/23 and rescheduled 2/23/23; hospital admission 1/24/23.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #1 | Medical Director and Treating Physician | Named in findings related to treatment decisions, ordering and follow-up of consults, and communication failures. |
| NP | Nurse Practitioner | Provided care to Resident #1, documented need for urology consult, and discussed combined gynecology/urology consult in notes. |
| LPN #1 | Licensed Practical Nurse | Provided care to Resident #1, performed catheterizations, and reported on resident's condition and complaints. |
| RN #1 | Registered Nurse | Provided care to Resident #1 and reported on antibiotic treatments and resident condition. |
| RN #2 | Registered Nurse | Reported on communication failures regarding consult orders and scheduling. |
| LPN #2 | Licensed Practical Nurse | Reported on resident's history, complaints, and procedures related to consult orders and transportation. |
| PT | Physical Therapist | Informed to evaluate Resident #1 for muscle pull but was refused by resident. |
| Scheduler | Appointment Scheduler | Scheduled gynecology appointments and reported on transportation failures causing missed appointments. |
| CNA #2 | Certified Nurse Assistant | Reported on resident's behavior, skin condition, and complaints. |
| DON | Director of Nursing | Provided information on consult scheduling and resident care. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 19, 2022
Visit Reason
The inspection was a Recertification Survey conducted from 12/13/2022 to 12/19/2022 to assess compliance with regulatory requirements for Putnam Nursing & Rehabilitation Center.
Findings
The facility was found deficient in medication labeling practices, specifically with insulin pens and multi-dose bottles not labeled with resident names and dates opened. Additionally, the infection prevention and control program was not properly implemented, as an LPN failed to use appropriate PPE when caring for COVID-19 positive residents.
Deficiencies (2)
F 0761: The facility did not ensure all drugs and biologicals were labeled according to accepted professional principles. Medication Cart #1 contained an open Novolog insulin pen and an open multi-dose bottle of Lispro insulin without resident name labels or dates opened.
F 0880: The facility failed to provide and implement an infection prevention and control program. An LPN did not use appropriate PPE, including eye protection and gowns, when providing care to two COVID-19 positive residents.
Report Facts
Residents affected: 2
Medication carts reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Named in medication labeling deficiency interviews | |
| Director of Nursing (DON) | Provided statements regarding medication labeling and infection control education | |
| Specialty Rx Pharmacy Representative | Provided information about insulin pen labeling | |
| Licensed Practical Nurse (LPN #4) | Named in infection control PPE deficiency | |
| Infection Preventionist (IP) | Provided statements regarding infection control education |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Dec 19, 2022
Visit Reason
Multiple isolated and patterned Level 2 deficiencies related to criminal history checks, accident hazards, infection control, drug labeling, electrical systems, hazardous areas, and smoke barriers were found and corrected.
Findings
Multiple isolated and patterned Level 2 deficiencies related to criminal history checks, accident hazards, infection control, drug labeling, electrical systems, hazardous areas, and smoke barriers were found and corrected.
Deficiencies (7)
Criminal history record check process
Free of accident hazards/supervision/devices
Infection prevention & control
Label/store drugs and biologicals
Electrical systems - essential electric syste
Hazardous areas - enclosure
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network was found; correction status not indicated.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network was found; correction status not indicated.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 21, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network was found; correction status not indicated.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network was found; correction status not indicated.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 1, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for Putnam Nursing & Rehabilitation Center.
Findings
The facility was found deficient in ensuring effective communication for a resident requiring a Polish interpreter and in maintaining a safe environment for a resident with Parkinson's Disease during wheelchair transport. Both deficiencies were cited with minimal harm and affected a few residents.
Deficiencies (2)
F 0676: The facility did not provide a Polish interpreter as required by the care plan for Resident #41, who had limited English proficiency, and staff did not know how to access language translation services.
F 0689: The facility failed to ensure safe wheelchair transport for Resident #104 with Parkinson's Disease, as staff pushed the wheelchair without checking foot placement, risking injury.
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN #1) | Unable to communicate with Resident #41 and stated no Polish interpreter was available | |
| Registered Nurse (RN #2) | Observed pushing Resident #104's wheelchair unsafely and acknowledged the safety issue | |
| Physical Therapist (PT) | Observed unsafe wheelchair transport of Resident #104 and was unaware of safety issues |
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