Below 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 Putnam County Care Center during CMS and state inspections, most recent first.
A deficiency was cited when an area of the facility was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was insufficient to ensure resident safety.
The facility did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a failure to meet required notification standards.
An Administrator disclosed a resident's change in code status from full code to DNR to a family member who was not the DPOA, and did so in a public setting at a golf course. This disclosure led to confusion and was acknowledged by the Administrator as a violation of both the resident's privacy and the facility's privacy policy, which require confidentiality of all resident health information.
Surveyors found that the facility did not ensure services were provided in accordance with professional standards of quality. The report did not specify the actions or omissions that led to this deficiency, nor did it provide details about the residents involved.
Staff did not follow proper infection control procedures while providing catheter care to two residents, including failing to change gloves and perform hand hygiene after perineal care and before catheter care, and improperly positioning urinary drainage bags above bladder level, resulting in observed backflow of urine and increased risk of infection.
A resident with severe cognitive impairment and a history of falls was left unattended in a raised bed without fall interventions in place, leading to a fall that resulted in a fatal head injury and hip fracture. Staff failed to implement care-planned interventions, contributing to the incident.
The facility failed to maintain a sufficient surety bond to protect the personal funds of 15 residents, as required by their policy. The bond was $10,000, while the required amount was at least $10,500 based on the average monthly balance. The Administrative Assistant responsible for the bond had not reviewed it in the past year, leading to this deficiency.
A resident with dementia and a history of wandering intruded into other residents' rooms, compromising their privacy. Despite a care plan to redirect the resident, they continued to disturb others by taking items and urinating in inappropriate places. Residents reported distress and used locks to prevent entry. Staff struggled to monitor the resident effectively, leading to repeated privacy invasions.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing specific medical needs. A resident with edema did not have this condition reflected in their care plan, despite physician orders for ace wraps. Another resident's care plan lacked guidance on managing multiple medications, including mood stabilizers and anti-coagulants. Additionally, a resident's care plan did not address the presence or care of a urinary catheter, leaving staff without necessary instructions.
The facility failed to update care plans for four residents, leading to deficiencies in addressing weight loss, choking episodes, and fall prevention. A resident with Parkinson's disease experienced significant weight loss and choking, but their care plan lacked necessary interventions. Another resident with dementia had multiple falls not documented in their care plan. Additionally, a resident with vitamin B12 deficiency and muscle wasting had significant weight loss without care plan updates, and a resident with diabetes and hypertension had multiple falls not reflected in their care plan.
A resident with dementia and a history of wandering was inadequately supervised, leading to repeated intrusions into other residents' rooms, causing fear and frustration. Despite having a care plan with interventions like alarm devices and redirection, the facility struggled to monitor the resident effectively, especially during night shifts. Staff and residents reported difficulties and distress due to the resident's behavior, highlighting a failure in implementing the facility's policies on wandering and safety.
The facility failed to ensure eight nurse aides completed their CNA certification within four months of employment, as required by policy. Interviews revealed that some aides had only recently started classes, while others were not enrolled. Staff cited issues with accessing online classes and a deliberate delay in enrollment to assess job retention, leading to non-compliance with certification requirements.
The facility did not offer bedtime snacks to all residents, as confirmed by resident interviews and staff admissions. Although a snack cart was available, it was not actively distributed, and residents had to request snacks. Staff inconsistently provided snacks, with some only offering them to diabetic residents. The DON and administrator acknowledged that snacks should be offered to all residents, indicating a gap between policy and practice.
The facility failed to follow infection control practices, including improper storage of respiratory supplies, inadequate hand hygiene, and PPE use during resident care. Additionally, urinary drainage systems were not kept off the floor, and TB screening for new employees was not completed before resident contact.
A facility failed to follow infection control practices for a resident with a urinary catheter, leading to potential urinary tract infections. The resident's care plan lacked documentation of the catheter and preventive measures. Observations showed the catheter drainage bag touching the floor, contrary to policy. Staff interviews confirmed this practice should be avoided to prevent contamination.
The facility failed to lock medication and treatment carts, leaving them unattended, and did not properly manage expired medications. A resident with Alzheimer's was at risk due to an unlocked cart, and an LPN admitted to forgetting to lock it. An expired medication was found in the medication room, indicating lapses in medication management procedures.
A resident with an indwelling urinary catheter experienced urinary retention with abnormal urine characteristics, but staff failed to notify the physician or document the condition. Despite facility policies requiring prompt notification and documentation, the LPN did not complete the necessary communication forms or inform the physician. The resident was later hospitalized with urosepsis, highlighting a breakdown in communication and assessment procedures among staff.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
The facility failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This deficiency was identified based on the lack of timely communication to all required parties when significant events impacting the resident occurred. The report specifically notes the absence of prompt notification following incidents or changes that had a direct effect on the resident's well-being or living situation.
Administrator Disclosed Resident's Code Status in Public, Violating Privacy Policy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records when the Administrator disclosed the resident's change in code status from full code to Do Not Resuscitate (DNR) to a family member who was not the resident's Durable Power of Attorney (DPOA), and did so in a public setting. The disclosure occurred while the Administrator was at a golf course, where the resident's family member and another unrelated individual were present. The Administrator informed the family member of the resident's change in code status, which led to a misunderstanding that the resident had experienced a code event. The family member subsequently shared this information with others and went to the facility, only to find the resident awake and confused. The resident's DPOA later stated that they did not want the resident's medical information shared with anyone else, emphasizing that the Administrator should not have disclosed the change in code status to other family members or in a public place. The Administrator acknowledged that she should not have shared the resident's personal medical information with anyone other than the DPOA, recognizing that this action violated both the resident's privacy and the facility's privacy policy. The facility's policy and federal law require that all resident information be kept confidential and only disclosed in accordance with privacy regulations.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the care and services delivered did not consistently adhere to accepted professional standards. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
Staff failed to utilize appropriate infection control techniques during the provision of care for two residents with indwelling urinary catheters. Observations revealed that certified nurse assistants (CNAs) performed perineal care on residents who were incontinent of bowel without changing their soiled gloves or performing hand hygiene before proceeding to catheter care. Specifically, after cleaning fecal matter, CNAs continued to handle the catheter tubing and perform catheter care with the same contaminated gloves, contrary to facility policy and standard infection control practices. Both residents involved had significant medical histories, including dependence for bed mobility and toileting, indwelling urinary catheters, and persistent bowel incontinence. Laboratory results for these residents indicated abnormal urinalysis findings and positive urine cultures for bacterial infections, with physician orders for antibiotics and ongoing catheter use. During care, staff also failed to maintain proper positioning of the urinary drainage bags, at times placing them above the level of the bladder, which resulted in observed backflow of urine into the catheter tubing. Interviews with staff and facility leadership confirmed that the expected practice was to change gloves and perform hand hygiene after perineal care and before catheter care, and to keep catheter bags below bladder level. However, staff did not consistently follow these protocols during observed care, directly leading to the identified deficiencies in infection control and catheter care.
Failure to Prevent Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate oversight and prevent injury for a resident who was dependent on staff for transfers and bed mobility and had a history of falls. The resident, who had severe cognitive impairment and required substantial assistance for bed mobility, fell out of bed on two occasions prior to the incident in question. Despite these previous falls, the facility did not evaluate or implement new interventions to prevent further falls. On the day of the incident, staff were preparing to transfer the resident out of bed for breakfast. The bed was raised, and the fall mat was removed from the floor. One CNA left the room to retrieve a mechanical lift, while the other CNA remained in the room but turned away from the resident to tidy up. During this time, the resident rolled out of bed and sustained a head injury and a hip fracture, which ultimately led to the resident's death. Interviews with staff revealed that the resident was supposed to have a low bed, fall mat, and pillows in place when in bed, but these interventions were not in place at the time of the fall. The staff's actions, including leaving the resident unattended and not implementing the care-planned interventions, directly contributed to the resident's fall and subsequent injuries.
Inadequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond to protect the personal funds of 15 residents held in the resident fund account. The facility's policy requires a surety bond to be at least one and a half times the average monthly balance of the residents' personal funds. However, the facility's surety bond, dated March 2, 2021, was only $10,000, while the required amount, based on the average monthly balance from September 2023 to September 2024, was calculated to be at least $10,500. The current ledger amount was $8,775.60, indicating a shortfall in the bond coverage. During an interview, the Administrative Assistant, who is responsible for managing the resident trust fund and obtaining the surety bond, admitted to not reviewing the bond in the past year. This oversight contributed to the facility's failure to ensure the bond was adequate to cover the residents' funds, as required by their policy. The facility census at the time was 55, highlighting the potential impact on a significant number of residents.
Resident Privacy Compromised by Wandering Resident
Penalty
Summary
The facility failed to ensure personal privacy for multiple residents due to the actions of a resident diagnosed with dementia and identified as a wanderer. This resident, who had a history of wandering prior to admission, frequently intruded into other residents' rooms, which was documented in the facility's records. Despite the resident's care plan indicating that they should be redirected and removed from other residents' rooms as needed, the resident continued to wander into rooms, taking items, urinating in inappropriate places, and disturbing other residents. Numerous residents reported incidents involving the wandering resident entering their rooms without permission. These incidents included the resident taking personal items, urinating in trash cans, and invading personal space, which caused distress among the residents. Some residents resorted to using child safety locks or other barriers to prevent the wandering resident from entering their rooms. Interviews with residents revealed a consistent pattern of unwanted intrusions, which they found troubling and upsetting. Staff interviews indicated that while efforts were made to monitor the wandering resident, they were not always successful in preventing the resident from entering other residents' rooms. The Director of Nursing acknowledged the resident's history of wandering and the challenges in managing their behavior. The facility's failure to adequately address the wandering behavior resulted in repeated invasions of privacy for multiple residents, as confirmed by both staff and resident interviews.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for three residents, which led to deficiencies in addressing their specific medical needs. Resident #22, who was admitted with a diagnosis of edema, did not have this condition identified in their baseline or comprehensive care plan. Despite observations of significant edema and physician orders for ace wraps, the care plan did not reflect these needs, nor did it provide guidance for staff on managing the condition. Resident #31, diagnosed with a left femur fracture, chronic pain syndrome, and schizoaffective disorder, was prescribed multiple medications, including mood stabilizers, anti-depressants, and anti-coagulants. However, the care plan lacked directions for staff regarding the use and potential side effects of these medications, leaving a gap in the management of the resident's complex medical regimen. Resident #47's care plan did not address the presence or care of a urinary catheter, despite documentation and observations confirming its use. The care plan failed to include necessary instructions for catheter care, which was also not reflected in the mini care plan. Interviews with staff revealed reliance on care plans for guidance, highlighting the importance of accurate and comprehensive documentation, which was not provided in these cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans of four residents to reflect their current care needs, as identified during a survey. Resident #26, who has Parkinson's disease and malnutrition, experienced significant weight loss over six months and had episodes of choking. Despite these issues, the resident's care plan did not include interventions for weight loss or therapeutic treatments. Interviews with CNAs revealed that the resident had been switched to a pureed diet temporarily due to choking episodes, but the care plan was not updated to reflect these changes. Resident #38, diagnosed with dementia, had a history of falls that were not documented in the care plan. The resident's care plan, revised in September 2024, did not include any fall prevention interventions despite the resident having multiple falls since admission. The care plan failed to reflect the resident's fall history, which included incidents in August 2024, March 2024, and November 2023. Resident #44, who suffers from vitamin B12 deficiency and muscle wasting, experienced a significant weight loss of over 13% in six months. However, the care plan did not address weight loss or include therapeutic treatments. Similarly, Resident #48, with type 2 diabetes and hypertension, had multiple falls that were not updated in the care plan. The MDS/Care Plan Coordinator acknowledged the issues with missing care plan updates, including falls and weight loss, and noted problems with the facility's matrix system.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia, identified as Resident #51, who exhibited wandering behavior. This resident, who had a history of wandering prior to admission, was observed entering other residents' rooms, causing distress among them. The resident's care plan included strategies such as equipping the resident with an alarm device and redirecting them as needed, but these measures were not effectively implemented. Observations showed the resident wandering unsupervised, attempting to access the medication room, and entering other residents' rooms, which led to fear and frustration among the other residents. Interviews with staff and residents revealed that the facility struggled to monitor Resident #51 effectively, especially during night shifts when staffing was limited. Staff members reported difficulties in keeping track of the resident, who often wandered into other residents' rooms, sometimes urinating in inappropriate places like trash cans. Residents expressed fear and frustration over the intrusions, with some feeling unable to protect themselves due to physical limitations. The facility's policies on wandering and behavioral assessment required identifying residents at risk and implementing interventions to ensure their safety. However, despite these policies, the facility did not adequately supervise Resident #51, leading to repeated incidents of wandering and intrusion into other residents' spaces. The Director of Nursing and the administrator acknowledged the challenges in supervising the resident and mentioned attempts to address the issue, such as installing safety knobs on doors, but these measures were insufficient to prevent the incidents.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that eight nurse aides completed a state-approved nurse aide training program within four months of their employment, as required by their policy. The nurse aides in question, identified as NA B, NA D, NA N, NA R, NA S, NA T, NA U, and NA V, were found to have no current CNA certification despite being employed for more than four months. Interviews with the nurse aides revealed that some had started CNA classes only recently, while others were not enrolled at all. The facility's policy mandates that nurse aides must complete the training program and competency evaluation within four months of hire, or they may face termination or reassignment to non-nursing roles. Interviews with facility staff, including the Human Resources/Administrative Assistant, Director of Nursing, and the Administrator, highlighted systemic issues in the enrollment and completion of CNA classes. The HR/Administrative Assistant mentioned difficulties accessing the online CNA class website, while the Director of Nursing indicated that the HR director was responsible for setting up these classes. The Administrator acknowledged awareness of the issue, stating that the facility delayed enrolling employees in CNA classes to ensure job retention before investing in their training. This approach led to non-compliance with the regulatory requirement for timely certification of nurse aides.
Failure to Offer Bedtime Snacks to All Residents
Penalty
Summary
The facility failed to offer bedtime snacks to all residents, as observed and reported by both residents and staff. During a group interview, 20 out of 20 residents stated that bedtime snacks were not offered, and staff did not come around to offer snacks in the evenings or at bedtime. Some residents mentioned that snacks were sometimes available at the nurse's station on a cart, but they had to ask for them. Observations confirmed the presence of a snack cart filled with various items, but it was not actively distributed to residents. Interviews with staff revealed inconsistencies in the distribution of bedtime snacks. A Certified Nurse Aide (CNA) mentioned that snacks were only passed to diabetic residents, while another CNA stated that although a cart of snacks was available, staff did not proactively offer them to all residents. The Director of Nursing and the administrator both acknowledged that CNAs should offer bedtime snacks to all residents, indicating a gap between policy and practice. This deficiency highlights a failure to adhere to the facility's policy of providing adequate nutrition and accommodating residents' needs and preferences regarding snack distribution.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices, particularly in the handling and storage of respiratory care supplies. Observations revealed that nasal cannula oxygen tubing for two residents was not stored in a plastic bag when not in use, as per facility policy. In one instance, the tubing was found on the floor and later used by the resident, indicating contamination. Additionally, the facility did not have specific orders regarding the changing or storage of respiratory equipment for these residents. The facility also failed to ensure proper hand hygiene and the use of personal protective equipment (PPE) during resident care. Staff members were observed not washing hands or changing gloves between dirty and clean tasks, and not wearing gowns when required by enhanced barrier precautions. This was noted during wound care and other high-contact activities for several residents. Furthermore, the facility did not ensure that urinary drainage systems were kept off the floor, as observed with one resident whose catheter tubing was repeatedly found touching the floor. Additionally, the facility did not follow its policy for tuberculosis (TB) screening for new employees. Three employees had their Tuberculin Skin Tests (TST) administered and read after they had already begun resident contact, contrary to the policy that requires testing before the first day of contact. Interviews with staff indicated a lack of clear responsibility for ensuring TB tests were completed as required, contributing to this oversight.
Infection Control Lapse in Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed to prevent urinary tract infections for a resident with a urinary catheter. The resident's urine culture report indicated significant bacterial presence, and an antibiotic was prescribed. However, the resident's care plan did not document the presence of a urinary catheter or include interventions to prevent urinary tract infections. Observations revealed that the resident's urinary catheter drainage bag frequently touched the floor, which is against the facility's policy and infection control practices. Interviews with staff, including a CNA, LPN, and the interim Director of Nursing, confirmed that no part of a urinary drainage system should touch the floor due to contamination risks. Despite this, the resident's catheter drainage bag was observed resting on the floor on multiple occasions, indicating a lapse in adherence to infection control protocols. The facility's policy on urinary catheter care, revised in August 2022, emphasizes keeping catheter tubing and drainage bags off the floor to prevent complications, including infections.
Medication Storage and Expired Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in multiple instances of unlocked and unattended medication and treatment carts. Observations revealed that a treatment cart was left unlocked and unattended near the nurse's station and in the hallway, with no staff in sight. This occurred despite the presence of a resident diagnosed with Alzheimer's disease, who was at risk of wandering into potentially dangerous areas. The Licensed Practical Nurse (LPN) admitted to forgetting to lock the cart while attending to a resident's blood sugar check and insulin administration. Additionally, the facility did not properly manage expired medications. An observation of the medication room found an open bottle of oyster shell calcium that had expired several months prior. The Certified Medication Technician (CMT) explained the process for handling expired medications, which involved placing them in a designated bin for destruction or return to the pharmacy. However, the expired medication was not appropriately managed, indicating a lapse in the facility's medication management procedures. The Director of Nursing confirmed that medication carts should be locked when unattended and that expired medications should be discarded or returned to the pharmacy.
Failure to Notify Physician and Document Urinary Status Leads to Urosepsis
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with an indwelling urinary catheter, leading to a severe health deficiency. The resident, who had a history of urinary retention, an enlarged prostate, and urinary tract infections, experienced an episode of urinary retention with tea-colored urine and a foul odor. Despite these abnormal findings, the staff did not notify the physician or document the resident's urinary status, which is a violation of the facility's policies. The resident was later admitted to the hospital with urosepsis, a life-threatening condition. The facility's policies require prompt notification of the physician and detailed documentation of any changes in a resident's condition, especially when there are signs of a urinary tract infection or catheter complications. However, the staff failed to adhere to these protocols. The LPN on duty did not complete the necessary SBAR communication form or notify the physician of the resident's abnormal urinary findings. Additionally, there was a lack of communication and follow-up among the staff regarding the resident's condition, which contributed to the delay in addressing the issue. Interviews with various staff members revealed a breakdown in communication and assessment procedures. Several staff members noticed changes in the resident's condition, such as lethargy, pus around the catheter, and decreased urine output, but these observations were not effectively communicated to the charge nurse or physician. The Director of Nursing and the Administrator acknowledged that the staff should have acted more quickly and communicated the resident's condition to the physician to prevent the progression of the urinary tract infection and subsequent hospitalization.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 57 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Unionville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Age Care Center | 17.6 mi | ★★★★★ | 1 | 0 |
| Mercyone Centerville Medical Center | 18.5 mi | ★★★★★ | 15 | 0 |
| Centerville Specialty Care | 19.3 mi | ★★★★★ | 6 | 0 |
| Milan Health Care Center | 21.3 mi | ★★★★★ | 1 | 0 |
| Schuyler County Nursing Home District | 23.2 mi | ★★★★★ | 30 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Putnam County Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.