Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Matulaitis Rehabilitation & Skilled Care during CMS and state inspections, most recent first.
A resident with dementia and a known elopement risk was found outside exterior fire doors after a fire alarm event in which a bathroom fan caught fire and activated the facility’s alarm system. Later observation showed that one of the exterior fire doors, controlled by a keypad and magnetic lock, did not latch shut on its own and had to be pulled closed, with interior weather stripping noted on the bottom of the door. The Maintenance Director reported that fire alarms disable door alarms and cause the doors to open automatically, acknowledged that the doors were old and known to require pulling to close, and stated that maintenance did not check the doors after the alarm to ensure they were secured. The DNS also confirmed that the exterior fire doors were not checked for secure closure following the fire event.
A resident with dementia, insomnia, repeated falls, and documented wandering was assessed as an elopement risk and placed in a room far from the nurses’ station and near an exterior exit. The care plan included only general interventions (e.g., orientation, frequent checks, familiar objects) and did not address specific behaviors such as nighttime wandering, confusion, searching for family, and packing belongings to leave. Psychiatric notes and staff interviews confirmed ongoing late-night wakefulness, agitation, and exit-seeking behaviors, and the resident was later found outside an alarmed exterior fire door. Despite facility policy requiring targeted elopement measures, the resident’s elopement care plan lacked individualized interventions tied to these known risk factors.
A resident with dementia, insomnia, a history of wandering, and moderately impaired cognition was assessed as at risk for elopement and had an elopement care plan, but no wander guard was applied despite facility policy. The resident was independently ambulatory, exhibited nighttime confusion and wandering, and was housed in a room far from the nurses’ station and closest to exterior fire doors. After a prior fire alarm event, maintenance did not verify that the exterior fire doors re-latched, even though the doors were known to require being pulled shut and had weather stripping that could impede closure. During the night, staff heard an alarm they did not recognize, later determined to be from the exterior fire doors, and found one door slightly ajar before discovering the resident missing and then located outside on the ground just beyond the doors. Staff, including nursing and CNAs, reported they had not participated in elopement drills, and leadership confirmed that no elopement drills had been conducted despite policy requiring periodic drills for residents at risk of wandering or elopement.
The facility failed to consistently document sanitizer concentration levels in the kitchen, as required by policy. Staff interviews and document reviews revealed missing entries in the sanitizer verification logs for several months, indicating that the sanitizing solution was not always checked before use. The Dietary Manager acknowledged the responsibility of dietary staff to verify and document the sanitizer concentration.
A resident admitted with a mid-back surgical incision did not have the surgical wound or related skin impairment included in their care plan, despite physician orders and facility policy requiring monitoring and care planning for such conditions. Interviews with the DNS and MDS Coordinator confirmed the omission, which was not addressed at the time of admission.
Two residents with altered skin integrity did not receive required wound measurements, and one used an external catheter device without a physician's order or staff training. Additionally, a Braden Scale pressure ulcer risk assessment was not completed on admission or at a change in condition for a resident with a worsening pressure ulcer, contrary to facility policy.
A resident admitted with a stage 4 pressure ulcer did not receive timely interventions, including delayed provision of an air mattress and turning schedule, and lacked prompt staging and assessment of the wound. The ulcer worsened significantly, and documentation of wound measurements was inconsistent, contrary to facility policy.
A resident with urinary incontinence and multiple comorbidities used an external catheter system without a physician's order, and staff interacted with the device without receiving any training. The family and a private aide managed the device without facility oversight, and there was no policy or staff education in place regarding its use.
A resident with dementia and other medical conditions was allegedly slapped by a nursing assistant during a night shift. The incident led to an investigation, conflicting statements from staff, and the termination of the nursing assistant for not adhering to the facility's dignity policy.
Failure to Ensure Exterior Fire Doors Securely Closed After Fire Alarm
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment by ensuring that exterior fire doors in a resident-accessible area were functional and able to securely close. A resident admitted with dementia, repeated falls, and insomnia had been identified as at risk for elopement, and an elopement care plan was in place. A reportable fire event occurred when a bathroom fan on one wing caught fire, triggering the fire alarm system and emergency response. Following this fire alarm, the exterior fire doors on another wing alarmed during the night, and a safety check revealed that the at-risk resident was found outside those exterior fire doors on their hands and knees, with no injuries identified at that time. Subsequent observation of the same exterior fire doors showed that, although they were locked and equipped with a keypad and magnetic locks, one of the two doors did not latch shut on its own and had to be pulled closed to secure it. The Maintenance Director stated that when the fire alarm is activated, the alarms on the exterior fire doors are disabled and the doors open automatically, and acknowledged that the prior fire alarm could have caused the doors to open and then not properly close and latch afterward. He also acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, despite knowing that the doors were old and required pulling to close, and that interior weather stripping might contribute to the failure to close securely. The DNS confirmed that after the fire event, the exterior fire doors were not checked to ensure they were secured and latched.
Failure to Individualize Elopement Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop a person-centered, individualized care plan to address an assessed elopement risk for one resident. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, leading to initiation of an elopement care plan. The Resident Care Plan documented that the resident was at risk for elopement related to dementia, with a history of wandering in the community and at the facility, and a past occupation as an elevator repair person who believed he had service calls and wanted to leave at night. Interventions listed were general in nature, such as introducing staff in a calm manner, explaining routines, orienting to room and environment, performing frequent checks, placing a picture in the business office, and encouraging family to bring familiar objects. The resident’s MDS showed moderately impaired cognition, independent ambulation of at least 150 feet, and wandering behaviors several days per week. Clinical documentation and interviews showed specific behaviors and circumstances that increased the resident’s elopement risk but were not reflected in individualized care plan interventions. Psychiatric notes over several months described late evening and early morning wakefulness, agitation, confusion, wandering, insomnia, and the resident looking for a family member at night, with PRN Trazodone ordered for agitation/insomnia. Staff interviews reported that the resident stayed up at night, wandered the hall, and packed belongings at night to go home. The resident’s room was located far from the nursing station and closest to an exterior fire door. An incident report documented that an exterior fire door alarm sounded during the night and the resident was found outside that door on hands and knees. Despite the facility’s written policy that residents identified as elopement risks would have a wander guard bracelet, photo ID placement, and periodic elopement drills, the care plan did not include individualized interventions addressing the resident’s nighttime wandering, confusion, searching for family, packing to leave, or room location near an exit, and the facility had not conducted or documented elopement drills.
Failure to Secure Exterior Fire Doors and Implement Elopement Interventions for At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that exterior fire doors in a resident-accessible area were secured and to provide adequate supervision and interventions for an ambulatory resident assessed as at risk for elopement, resulting in the resident exiting the building unsupervised. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, with an elopement care plan initiated. The resident care plan documented dementia-related elopement risk, a history of wandering in the community and at the facility, and a past occupation as an elevator repair person with a pattern of thinking he had service calls and wanting to leave at night. Interventions listed included calm introductions, explanation of routines, orientation to room and environment, frequent checks as necessary, a picture in the business office, and encouraging family to bring familiar objects; no wander guard was initiated at that time. Clinical documentation showed the resident had late evening and early morning wakefulness, agitation, confusion, and wandering, including middle-of-the-night confusion and looking for a family member, with PRN Trazodone ordered for agitation/insomnia. The quarterly MDS identified moderately impaired cognition (BIMS 11), independent ambulation of at least 150 feet, and wandering behaviors occurring one to three days per week. A fall assessment tool identified the resident as high risk for falls. Despite these findings and the facility’s own policy stating that residents identified as elopement risks should have a wander guard bracelet initiated and checked each shift, the DNS stated the resident did not have a wander guard because the resident was not considered exit seeking or making statements of wanting to leave. The DNS also acknowledged that the resident’s room, which was the closest to the exterior fire doors and farthest from the nursing station, was the only room available at admission. On the night of the event, a bathroom fan fire on another wing had triggered the fire alarm the previous day, which the Maintenance Director stated could cause exterior fire doors to open and then not close and latch properly once the alarm was completed. He acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, and that the D-wing exterior fire doors were known to require being pulled shut to secure, with weather stripping possibly contributing to incomplete closure. In the early morning hours, staff heard an alarm they did not recognize and initially did not know it was from the exterior fire doors; they required direction from the supervisor to check those doors. The NA found the D-wing exterior fire door slightly ajar, closed it, and then began a resident head count, discovering the resident missing from the room nearest the doors. When the exterior doors were opened, the resident—who had been last seen in bed around midnight and was known to pack belongings at night to go home—was found outside on hands and knees. Both the NA and RN reported they had not participated in any elopement drills, and the DNS confirmed the facility had not conducted elopement drills and had no documentation of such drills, despite policy requiring periodic elopement drills for residents at risk for wandering/elopement.
Inconsistent Sanitizer Verification in Kitchen
Penalty
Summary
The facility failed to consistently complete sanitation logs for the sanitizing sink according to its policy. During a kitchen tour, a dietary aide was observed washing a pitcher in a 3-bay sink, with two large gray baking pans soaking in the sanitizing sink. The dietary aide admitted to not checking the sanitizer concentration level, relying on the cook who checked it in the morning. A review of facility documentation revealed that the sanitizer level was not checked before washing and sanitizing breakfast dishes. Furthermore, the pot sink and bucket sanitizer verification logs from June to December 2024 showed missing documentation for breakfast and lunch times across several months. Interviews with staff revealed that the sanitizing sink was filled with solution in the morning, but the concentration test results were not always documented. The Dietary Manager confirmed that it was the dietary staff's responsibility to check the sanitizing solution before use and acknowledged that staff might forget to document the concentration. The facility's policy requires that testing of the sanitizing solution be documented each time the sink is refilled, and the person filling the sink is responsible for this documentation.
Failure to Timely Update Care Plan for Surgical Incision on Admission
Penalty
Summary
The facility failed to timely review and revise the care plan to address a surgical incision present on admission for one resident. The resident, who had a history of spinal fusion, chronic congestive heart failure, urinary incontinence, muscle weakness, and required assistance with personal care, was admitted with a mid-back surgical incision. The admission observation and physician's order both documented the presence of the incision and directed staff to monitor it for signs of infection every shift. However, the care plan did not identify the actual skin impairment related to the surgical wound. Interviews with the Director of Nursing Services and the MDS Coordinator confirmed that a care plan for the surgical incision should have been initiated upon admission, but this was missed. Facility policy required that the comprehensive, person-centered care plan include all identified problem areas and risk factors, but the surgical wound was not incorporated into the resident's care plan as required.
Failure to Assess Wounds, Obtain Orders for Medical Devices, and Complete Pressure Ulcer Risk Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with altered skin integrity. For one resident with a history of spinal fusion, chronic congestive heart failure, urinary incontinence, and muscle weakness, the facility did not measure two surgical incisions from admission through discharge, despite policy requiring weekly wound assessments including measurements. Documentation showed that staff were unable to assess the incision on admission due to family refusal, but there was no evidence of subsequent measurements or documentation throughout the resident's stay. Interviews with clinical staff confirmed that wound protocols were not followed, and the Director of Nursing was unable to explain the lack of measurements. Additionally, the same resident utilized an external catheter device throughout their stay without a physician's order, as documented in nursing notes. The device was applied and removed by the family and a private aide, with facility staff only turning it on/off or emptying it as needed, despite not being trained on its use. There was no facility policy or staff training regarding the external catheter, and the Director of Nursing acknowledged that a physician's order should have been obtained and that staff should not have managed the device without proper oversight. For a second resident with a right femur fracture, Parkinson's disease, dementia, and a stage 4 pressure ulcer, the facility failed to complete a Braden Scale pressure ulcer risk assessment on admission and at a change in condition, as required by policy. The resident was admitted with a pressure ulcer, which worsened during the stay, but the Braden Scale was not completed until 25 days after admission. Interviews with nursing leadership confirmed that the assessment should have been done on admission and with the change in condition, but they were unable to explain the omission.
Failure to Provide Timely Pressure Ulcer Interventions and Assessment
Penalty
Summary
A deficiency occurred when a resident admitted with a stage 4 pressure ulcer did not receive timely and appropriate interventions as required by facility policy. Upon admission, the resident was noted to have a pressure ulcer to the coccyx, but the ulcer was not staged, and a Braden Scale assessment to identify risk for further skin breakdown was not completed in a timely manner. The initial care plan included interventions such as a pressure-relieving mattress and repositioning, but an air mattress was not provided until three days after admission, despite the presence of a pressure ulcer. Orders for regular turning and repositioning were also delayed until three days post-admission. The clinical record showed that the pressure ulcer increased in size significantly within a few days, and there was a lack of consistent and timely wound measurements and assessments, with a ten-day gap in documentation. The wound was not staged or assessed according to facility policy, which requires weekly assessments. The resident's condition deteriorated, with the ulcer worsening and signs of infection developing, leading to a transfer to the emergency department for further evaluation. Upon return, a wound care consult was ordered, and the wound was found to have slough and necrotic tissue, requiring debridement and specialized wound care products. Interviews with facility staff confirmed that the expected interventions, such as providing an air mattress and implementing a turning schedule, were not initiated on admission as required. The Director of Nursing Services and a registered nurse acknowledged the delay in implementing these interventions and the lack of timely wound assessment and staging. The facility's policies require immediate risk assessment, staging, and implementation of pressure ulcer prevention and treatment measures, which were not followed in this case.
Lack of Staff Training and Oversight for External Catheter Use
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for a resident using an external catheter system. The resident, who had a history of spinal fusion, chronic congestive heart failure, urinary incontinence, and previous UTIs, was documented as using an external catheter during their stay. However, there was no physician's order for the device, and the care plan only addressed general incontinence care without mention of the external catheter. Facility staff did not apply or remove the catheter, but did turn it on/off and emptied it as needed, despite not having received any training on the device. The family and a private aide were allowed to manage the catheter without facility oversight. Interviews with staff and administration confirmed that there was no policy or staff education regarding the use of the external catheter system. The DNS acknowledged that the facility permitted the family and private aide to manage the device and that staff interacted with the device without proper training. No policy on the external catheter system was provided when requested, and the APRN stated that the device should not have been used without a physician's order and appropriate staff training due to infection risks.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity. Resident #1, who had diagnoses including dementia with psychotic disturbances, infection to cystostomy catheter, heart failure, and depression, was involved in an incident where a nursing assistant (NA #1) allegedly slapped the resident. The incident occurred during the night shift when Resident #1 was restless and attempting to get out of bed. Another nursing assistant (NA #2) reported witnessing NA #1 slap Resident #1 in the face, which led to an immediate investigation and the removal of NA #1 from care duties. NA #1 denied slapping the resident but admitted to placing her hand over the resident's mouth to quiet him down, which was deemed inappropriate by the facility's Director of Nursing (DON). The facility's policy on dignity and respect was not followed, leading to the termination of NA #1's employment. The incident report and investigation revealed conflicting statements from the involved staff members, making it difficult to substantiate the abuse claim. However, the DON acknowledged that NA #1's actions were not in line with the facility's policy on treating residents with dignity and respect. The facility's Quality of Life - Dignity Policy emphasizes that each resident should be cared for in a manner that promotes their well-being and self-esteem. The failure to adhere to this policy resulted in the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Putnam
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westview Health Care Center | 3.2 mi | ★★★★★ | 3 | 0 |
| Lanessa Extended Care | 7.7 mi | ★★★★★ | 1 | 0 |
| Webster Manor Rehabilitation & Health Care Center | 7.7 mi | ★★★★★ | 3 | 0 |
| Overlook Nursing And Rehabilitation Center | 7.9 mi | ★★★★★ | 0 | 0 |
| Davis Place | 8.2 mi | ★★★★★ | 2 | 0 |
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