Inspection Reports for
Putnam Ridge
46 Mt Ebo Road North, Brewster, NY, 10509
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Inspection Report — Sep 29, 2025
Annual Inspection CMS
Date: Sep 29, 2025
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements and resident care standards at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to honor resident choice in care provider assignment, delayed reporting of suspected abuse, incomplete and non-comprehensive care plans, inadequate provision of activities to meet resident needs, insufficient supervision to prevent accidents, and inadequate staffing to meet behavioral health needs of residents.
Citations (6)
F 0561: The facility failed to honor resident choice by allowing Certified Nurse Aide #23 to provide care to Resident #75 despite a request not to assign this aide.
F 0609: The facility did not timely report suspected abuse for Resident #164, reporting bruises more than 2 hours after suspicion arose.
F 0656: The facility failed to develop and implement comprehensive care plans with measurable objectives for multiple residents, including lack of plans for staff assistance, restraints, and ordered devices.
F 0679: The facility did not ensure activities met resident preferences and interests, resulting in residents wandering unsupervised and missing activities.
F 0689: The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in a fall with injury for Resident #164 and inadequate hourly safety checks for Resident #116.
F 0741: The facility lacked sufficient staff with competencies and skills to meet behavioral health needs, failing to consistently implement thirty-minute checks and supervision for Resident #20 with wandering and inappropriate behaviors.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Thirty-minute check documentation missing: 27
Thirty-minute check documentation missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #23 | Certified Nurse Aide | Named in care provider choice deficiency for Resident #75 |
| Certified Nurse Aide #7 | Certified Nurse Aide | Named in abuse and accident investigation for Resident #164 |
| Director of Nursing | Director of Nursing | Involved in investigation and interviews regarding multiple deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interviews and statements regarding investigations and care plan deficiencies |
| Registered Nurse Unit Manager #11 | Registered Nurse Unit Manager | Interviewed regarding care plans, supervision, and staffing issues |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Notified about bruising on Resident #164 and involved in investigation |
| Nurse Practitioner #1 | Nurse Practitioner | Assessed Resident #164 and provided medical orders |
| Director of Social Work | Director of Social Work | Interviewed regarding resident rights and behavioral health staffing |
| Director of Recreation | Director of Recreation | Interviewed regarding resident activities and participation |
Inspection Report — Sep 29, 2025
Certification/complaint State
Date: Sep 29, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2025 with detailed deficiency and enforcement history.
Complaint Details
The state logged 53 complaints about this facility; 10 led to on-site inspections. Complaint surveys were conducted on July 7, 2025; April 23, 2025; December 16, 2024; August 14, 2023; and September 27, 2022.
Findings
Across 8 inspections, the facility received 70 citations including 58 standard health and 12 Life Safety Code violations. Two enforcement actions with fines totaling $14,000 were recorded, and multiple deficiencies were corrected while some remained uncorrected at the time of reporting.
Citations (42)
Standard Health Citation — quality of care: Activities did not meet interests or needs of each resident.
Standard Health Citation — quality of care: Care plans were not timely revised as required.
Standard Health Citation — quality of care: Failed to develop and implement a comprehensive care plan.
Standard Health Citation — quality of care: Food procurement, storage, preparation, or serving was not sanitary.
Standard Health Citation — quality of care: Facility was not free of accident hazards or lacked proper supervision/devices.
Standard Health Citation — quality of care: Infection prevention and control measures were inadequate.
Standard Health Citation — quality of care: Quality of care deficiencies noted.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Standard Health Citation — quality of care: Resident rights were not fully exercised or protected.
Standard Health Citation — quality of care: Residents were not free from physical restraints as required.
Standard Health Citation — quality of care: Self-determination was not adequately supported.
Standard Health Citation — quality of care: Staffing was insufficient or not competent to meet behavioral health needs.
Standard Health Citation — quality of care: Treatment and services to prevent or heal pressure ulcers were inadequate.
Life Safety Code Citation — NFPA requirements: Cooking facilities did not meet code requirements.
Life Safety Code Citation — NFPA requirements: EP testing requirements were not met.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance was deficient.
Life Safety Code Citation — NFPA requirements: Hazardous areas were not properly enclosed.
Life Safety Code Citation — NFPA requirements: HVAC system did not meet code requirements.
Life Safety Code Citation — NFPA requirements: Maintenance, inspection, and testing of doors was inadequate.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike environment was not maintained.
Standard Health Citation — quality of care: ADL care provided for dependent residents was deficient.
Standard Health Citation — quality of care: Feeding assistant training and supervision was inadequate.
Standard Health Citation — quality of care: Residents were not free of significant medication errors.
Standard Health Citation — quality of care: Nursing staff was insufficient.
Standard Health Citation — quality of care: Bowel/bladder incontinence, catheter, and UTI care was deficient.
Standard Health Citation — quality of care: Facility assessment was inadequate.
Standard Health Citation — quality of care: Free of accident hazards and supervision was deficient.
Standard Health Citation — quality of care: Residents were not free of significant medication errors.
Standard Health Citation — quality of care: Sufficient nursing staff was lacking.
Standard Health Citation — quality of care: Department criminal history review was deficient.
Standard Health Citation — quality of care: Facility hiring and use of nurse aides was deficient.
Standard Health Citation — quality of care: Labeling and storage of drugs and biologicals was deficient.
Standard Health Citation — quality of care: Notification of changes (injury/decline/room) was deficient.
Standard Health Citation — quality of care: Nurse aide performance review and in-service training was deficient.
Standard Health Citation — quality of care: Reasonable accommodations for needs and preferences were deficient.
Life Safety Code Citation — NFPA requirements: Discharge from exits was deficient.
Life Safety Code Citation — NFPA requirements: Fire drills were deficient.
Life Safety Code Citation — NFPA requirements: Horizontal sliding doors were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was deficient.
Standard Health Citation — quality of care: Free from abuse and neglect was deficient.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Standard Health Citation — quality of care: Notification of changes (injury/decline/room) was deficient.
Report Facts
Total inspections: 8
Total citations: 70
Standard Health citations: 58
Life Safety Code citations: 12
Complaints: 53
On-site complaint inspections: 10
Enforcement actions: 2
Total fines: 14000
Citations from complaints: 39
Inspection Report — Jul 7, 2025
Abbreviated Survey CMS
Date: Jul 7, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with maintaining safe and comfortable temperature levels during a heat emergency after an air-conditioning unit failure on the Dogwood unit.
Findings
The facility failed to ensure that resident room temperatures were adequately monitored during the air-conditioning breakdown on the Dogwood unit from 06/23/2025 to 06/24/2025. Hallway temperatures remained within regulation, but no documentation existed for resident room temperatures during the outage.
Citations (1)
F 0584: The facility did not document that resident room temperatures were adequately monitored during the air-conditioning failure on the Dogwood unit from 06/23/2025 to 06/24/2025, contrary to the Heat Emergency policy requirements.
Report Facts
Temperature readings: 71
Temperature readings: 78.6
Temperature readings: 78.3
Inspection Report — Apr 23, 2025
Abbreviated Survey CMS
Date: Apr 23, 2025
Visit Reason
The visit was an abbreviated survey conducted from 4/21/25 to 4/23/25 to assess compliance with regulatory requirements including resident care, staffing, medication administration, infection control, and feeding assistance.
Findings
The facility was found deficient in maintaining residents' dignity during meal service, providing adequate assistance with activities of daily living, ensuring proper medication administration, maintaining sufficient staffing levels, ensuring feeding assistants were properly trained, and enforcing infection prevention and control practices.
Citations (7)
F 0550: The facility did not maintain residents' dignity as residents ate meals in hallways due to dining room closure and staff referred to residents requiring feeding assistance as 'feeders' in the presence of others.
F 0677: The facility failed to ensure residents unable to perform activities of daily living received necessary care, including toileting and feeding assistance, resulting in residents waiting long periods for care.
F 0684: Resident #8 did not receive immediate-use seizure medication (Diazepam nasal spray) as prescribed, resulting in hospitalization after a prolonged seizure.
F 0725: The facility did not provide sufficient nursing staff on multiple shifts across several months, leading to delays in resident care and increased workload for staff.
F 0760: Resident #12 received a duplicate order of Baclofen, resulting in administration of twice the prescribed dose for three days.
F 0811: The facility did not ensure feeding assistants were trained and supervised according to state requirements; Unit Assistant #26 feeding Resident #11 lacked documentation of state-approved training.
F 0880: Infection prevention and control practices were not followed; staff entered isolation rooms without proper PPE or hand hygiene, contaminated milk cartons, and a resident positive for respiratory syncytial virus was unmasked and roaming hallways.
Report Facts
Staffing shortages: 4
Staffing shortages: 1
Staffing shortages: 1
Staffing shortages: 4
Staffing shortages: 1
Staffing shortages: 2
Staffing shortages: 5
Staffing shortages: 2
Medication error: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #20 | Named in dignity and feeding assistance deficiencies related to referring residents as 'feeders' and delays in feeding assistance | |
| Activities Leader #4 | Named in dignity deficiency for referring resident as 'feeder' and observed not following infection control precautions | |
| Licensed Practical Nurse #3 | Named in dignity and infection control deficiencies for meal service and improper handling of milk carton | |
| Registered Nurse Unit Manager #1 | Interviewed regarding staffing shortages, medication errors, and infection control practices | |
| Licensed Practical Nurse #22 | Named in medication error deficiency related to administration of double dose of Baclofen | |
| Licensed Practical Nurse #24 | Named in medication error deficiency for crushing extended-release medication and signing for medication not given | |
| Unit Assistant #26 | Observed feeding resident without documented state-approved feeding assistant training | |
| Infection Preventionist Registered Nurse | Interviewed regarding infection control policies and practices | |
| Director of Nursing | Interviewed regarding feeding assistant training and medication error | |
| Director of Human Resources | Interviewed regarding feeding assistant training | |
| Nurse Practitioner #1 | Observed not following infection control precautions during resident visits |
Inspection Report — Dec 16, 2024
Abbreviated Survey CMS
Date: Dec 16, 2024
Visit Reason
The facility underwent an abbreviated survey to assess compliance with regulatory standards related to resident care, medication administration, staffing, accident prevention, and facility-wide resource assessment.
Findings
The survey found multiple deficiencies including residents without identification bands, inadequate fall prevention interventions, insufficient documentation of incontinence care, medication administration errors including late doses and lack of physician notification, staffing shortages below facility guidelines, and an incomplete facility-wide assessment of resources necessary for resident care.
Citations (6)
F0684: The facility did not ensure 12 residents on the Apple unit had identification bands in place during medication administration.
F0689: The facility failed to prevent accidents and provide adequate supervision for 2 residents with multiple falls and no documented interventions.
F0690: Resident #1 did not receive appropriate incontinence care as documented by numerous missed care occasions from May to September 2024.
F0725: The facility did not provide sufficient nursing staff on Unit A to meet resident needs, with multiple shifts below the staffing plan requirements.
F0760: Medication administration errors occurred for 3 residents, including late administration of Depakote and Carbidopa-Levodopa and failure to notify physicians or document refusals.
F0838: The facility-wide assessment did not include staffing plans or review of staff assignments necessary for competent resident care during all shifts.
Report Facts
Residents without identification bands: 12
Residents reviewed for identification bands: 39
Falls for Resident #2: 5
Falls for Resident #3: 4
Missed bladder incontinence care occasions for Resident #1 in May 2024: 9
Missed bowel incontinence care occasions for Resident #1 in May 2024: 5
Missed bladder incontinence care occasions for Resident #1 in June 2024: 19
Missed bowel incontinence care occasions for Resident #1 in June 2024: 21
Missed bladder incontinence care occasions for Resident #1 in July 2024: 67
Missed bowel incontinence care occasions for Resident #1 in July 2024: 35
Missed bladder incontinence care occasions for Resident #1 in August 2024: 94
Missed bowel incontinence care occasions for Resident #1 in August 2024: 46
Missed bladder incontinence care occasions for Resident #1 in September 2024: 43
Missed bowel incontinence care occasions for Resident #1 in September 2024: 15
Residents on Unit A: 39
Certified Nursing Assistants scheduled below plan on day shifts in May 2024: 9
Certified Nursing Assistants scheduled below plan on night shifts in May 2024: 1
Medication late administration occurrences for Resident #1 Depakote: 6
Medication late administration occurrences for Resident #2 Carbidopa-Levodopa: 5
Medication refusals for Resident #3 Trazodone and Melatonin: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Interviewed regarding identification band issues and medication administration. | |
| Registered Nurse #1 | Interviewed about identification band audits and incontinence care documentation. | |
| Director of Nursing | Director of Nursing | Provided statements on identification band policies, fall risk meetings, staffing, and medication administration. |
| Administrator | Administrator | Discussed staffing improvements and quality assurance meetings. |
| Certified Nursing Assistant #3 | Reported staffing shortages and issues with staff coverage. | |
| Certified Nursing Assistant #5 | Reported staffing shortages and resident care assignments. | |
| Certified Nursing Assistant #6 | Reported staffing levels and resident care challenges. | |
| Staffing Coordinator/Nursing Recruiter | Described staffing plans and use of agency staff. | |
| Licensed Practical Nurse #3 | Interviewed about medication administration timing for Resident #1. | |
| Licensed Practical Nurse #4 | Interviewed about medication administration timing and documentation. | |
| Licensed Practical Nurse #5 | Interviewed about medication administration documentation errors. | |
| Licensed Practical Nurse #6 | Interviewed about medication administration timing for Resident #2. |
Inspection Report — Oct 25, 2023
Annual Inspection CMS
Date: Oct 25, 2023
Visit Reason
The inspection was conducted as a recertification survey and abbreviated surveys to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, call bell accessibility, investigation of injuries of unknown origin, provision of personal hygiene care, medication administration errors, supervision to prevent accidents, nurse aide training and competency, medication error rates, medication storage, and food safety practices.
Citations (11)
F 0550: The facility did not ensure privacy for Resident #62 with a Foley catheter bag that was not concealed from public view.
F 0558: The call bell system was not accessible for 7 of 12 residents reviewed, with call bells not within reach as required by care plans.
F 0610: The facility did not thoroughly investigate injuries of unknown origin for Resident #449, including a broken arm and skin tear, and failed to report to the state as required.
F 0677: Resident #64 was observed with urine-soaked pants and was not toileted or gotten out of bed as planned, indicating inadequate assistance with activities of daily living.
F 0684: Medication errors occurred for Residents #23, #299, and #105 including incorrect dosing, failure to provide aide escort to appointment, and administration of crushed medications without physician order.
F 0689: Resident #302, at high risk for falls, was observed attempting to stand from wheelchair without staff assistance or redirection.
F 0728: Seven training nurse aides were functioning without nurse aide certification beyond the allowed 4 months.
F 0730: Four certified nurse aides lacked required annual in-service education hours and performance evaluations.
F 0759: Medication error rate exceeded 5% with errors including crushing extended-release tablets and failure to flush feeding tubes between medications.
F 0761: Medications on Cedar and Apple unit carts were stored in unclean conditions with expired, undated, and unlabeled drugs and biologicals present.
F 0812: Food items in kitchen refrigerators were unlabeled and undated, and a rack designated for dry pans was wet, violating food safety standards.
Report Facts
Medication error rate: 12
Residents affected by call bell accessibility: 7
Nurse aides without certification: 7
Certified nurse aides lacking in-service hours: 4
Certified nurse aides lacking performance evaluations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error for administering incorrect dose of Clonazepam to Resident #23 |
| LPN #4 | Licensed Practical Nurse | Observed crushing extended-release medication for Resident #132 without order |
| LPN #7 | Licensed Practical Nurse | Observed not flushing feeding tube between medications for Resident #136 |
| Director of Nursing | Director of Nursing | Provided statements regarding multiple deficiencies including medication errors, call bell accessibility, and staff training |
| Director of Human Resources | Director of Human Resources | Provided statements regarding nurse aide certification and training |
| RN #2 | Registered Nurse | Observed medication cart conditions and provided statements on cleaning and expired medications |
| LPN #3 | Licensed Practical Nurse | Observed medication cart conditions and provided statements on cleaning and expired medications |
| Assistant Food Service Director | Assistant Food Service Director | Provided statements on food labeling and safety |
| Food Service Director | Food Service Director | Provided statements on food labeling and safety |
Inspection Report — Aug 14, 2023
Abbreviated Survey CMS
Date: Aug 14, 2023
Visit Reason
The visit was conducted as an abbreviated survey to investigate allegations of abuse involving residents at the facility.
Findings
The facility failed to ensure residents were free from abuse, with one Certified Nursing Aide (CNA #1) verbally abusing and roughly handling Resident #2. Additionally, the facility did not timely report alleged abuse incidents involving Residents #1 and #2 to the New York State Department of Health as required.
Citations (2)
F 0600: The facility did not protect Resident #2 from verbal and physical abuse by CNA #1, who was witnessed calling the resident demented and handling them roughly during care and transfer.
F 0609: The facility failed to timely report suspected abuse involving Residents #1 and #2 to the New York State Department of Health, delaying notification beyond the required timeframe.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for abuse: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Named in verbal and physical abuse findings involving Resident #2. |
| Director of Nursing | Director of Nursing (DON) | Conducted investigations and interviews related to abuse allegations. |
| Registered Nurse Unit Manager | RNUM | Reported abuse allegations to DON and Administrator. |
| Administrator | Facility Administrator | Interviewed regarding abuse allegations and reporting. |
Inspection Report — Sep 23, 2020
CMS
Date: Sep 23, 2020
Visit Reason
The inspection was conducted as an Extended Survey to evaluate the facility's administration and resource management, specifically regarding the monitoring and inspection of hoyer pads used for resident transfers.
Findings
The facility failed to administer resources effectively by not having a system in place to monitor, inspect, and document the condition of hoyer pads. An incident occurred where a resident fell due to a snapped hoyer sling strap, and staff did not document inspections of the equipment.
Citations (1)
F 0835: The administrator failed to have a system for monitoring, inspecting, and documenting the condition of hoyer pads. Staff checked hoyer pads but did not document inspections, leading to equipment failure and resident injury.
Report Facts
Date of incident investigation completion: Sep 17, 2020
Date of interviews: Sep 18, 2020
Date of interview: Sep 22, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Completed investigation and removed faulty equipment | |
| Director of Environmental Services | Interviewed regarding hoyer pad checks | |
| Facility Administrator | Interviewed regarding inspection documentation of hoyer pads | |
| Nurse Educator | Interviewed regarding hoyer lift in-service training |
Inspection Report — Jul 25, 2018
Annual Inspection CMS
Date: Jul 25, 2018
Visit Reason
The survey was conducted as a recertification annual inspection to evaluate compliance with federal regulations and assess the quality of care provided to residents.
Findings
The facility was found deficient in multiple areas including care plan implementation, communication with dialysis centers, restraint use, medication management, infection control, food safety, and staff training. Deficiencies were generally of minimal harm but affected several residents.
Citations (8)
F 0656: The facility failed to maintain effective communication with the dialysis center for Resident #140 and did not address Resident #24's ongoing weight gain or ensure proper use and release of restraints for Resident #95.
F 0657: The facility did not revise the care plan for Resident #140 to address ongoing constipation issues following hospitalization and discontinued bowel protocols without replacement interventions.
F 0693: The facility failed to ensure Resident #31 received prescribed automatic water flushes for hydration via feeding tube due to pump mismanagement.
F 0758: The facility did not adequately document or evaluate the use of antipsychotic medication Zyprexa for Resident #31, including failure to consider infection as a cause of behavior changes and lack of behavioral monitoring.
F 0761: Medications were not stored and labeled properly; insulin pens and vials were opened, undated, and unlabeled on the Birch Unit medication cart.
F 0812: Food items in resident refrigerators on Cedar and Dogwood units were not properly labeled or dated, risking foodborne illness.
F 0880: Infection control practices were inadequate; staff failed to use personal protective equipment when caring for a resident on contact precautions and equipment was contaminated by dragging on the floor.
F 0947: The facility did not provide required annual in-service training on dementia care and abuse prevention for 10 of 10 CNAs reviewed.
Report Facts
Weight increase: 11.8
Medication training hours: 0.75
Medication training hours: 2.25
Medication training hours: 1
Medication training hours: 0.75
Medication training hours: 2.3
Medication training hours: 4.5
Medication training hours: 2.5
Medication training hours: 2
Medication training hours: 1.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse Manager | Interviewed regarding dialysis communication, weight monitoring, restraint use, and bowel protocol |
| RN #2 | Registered Nurse Manager | Interviewed regarding feeding tube hydration and antipsychotic medication monitoring |
| LPN #2 | Licensed Practical Nurse | Observed not using PPE with resident on contact precautions |
| In-service Coordinator | Interviewed regarding CNA training program oversight |
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