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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and functional limitations was involved in two incidents where staff failed to follow the care plan requiring a two-person assist. In one incident, a CNA used a Hoyer lift alone, and in another, the resident bumped their head during care. The resident sustained significant injuries, including a brain bleed and broken neck, leading to their death. The Medical Examiner found the injuries inconsistent with the explanations provided.
The facility was cited for failing to ensure proper food storage and sanitation practices. Observations revealed unlabeled and undated food items in kitchen storage areas, improper use of hairnets and beard covers by staff, and unsanitary kitchen conditions. Additionally, pantry refrigerators had temperature issues and cleanliness concerns, with open and unlabeled bottles found. The Food Service Director acknowledged these deficiencies.
Three residents in the facility did not receive proper positioning and mobility care. A resident with a left-hand contracture was not provided with a positioning device, and there was no care plan or physician's orders for their condition. Another resident using a tilt-in-space wheelchair was not positioned correctly, with staff lacking guidance on its use. A third resident at risk for pressure ulcers did not consistently receive heel boots as ordered, with missing documentation of their application.
The facility failed to maintain a safe, clean, and homelike environment on the 2nd and 3rd floors, with issues such as a strong urine odor, broken furniture, stained walls, and soiled privacy curtains. Staff interviews revealed insufficient staffing and lack of routine maintenance checks, contributing to these deficiencies.
A resident requiring extensive assistance with personal hygiene was observed with long, stained fingernails and a contracted hand, despite facility policies and care plans mandating regular nail care. Staff interviews confirmed the oversight, highlighting a failure to adhere to the resident's care plan.
Two residents lacked comprehensive care plans for positioning and mobility needs. One resident with a hand contracture had no care plan addressing the condition, while another using a specialized wheelchair lacked positioning instructions. Staff interviews revealed awareness of these issues but no documented care plans or education for staff on proper positioning.
Housekeeping staff failed to adhere to infection control practices in a room under Droplet Precautions. One housekeeper entered without a gown and did not remove gloves upon exiting, while another wore a surgical mask instead of the required N-95 mask. Both acknowledged their errors, and the supervisor confirmed staff were educated on proper PPE use.
The facility did not ensure required attendance of the Medical Director and Infection Control Practitioner at QAPI meetings, with the Medical Director missing three out of four meetings and the Infection Control Practitioner absent from two. The Administrator acknowledged the issue, citing previous personnel changes.
The facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours on one occasion, as required by regulation. This deficiency was identified during a survey, revealing that no RN was present on a specific date, despite the facility's staffing plan requiring RN coverage on all shifts. Interviews with the Director of Human Resources and the Director of Nursing confirmed the absence and their awareness of the requirement.
A life safety survey revealed that the facility failed to maintain structural components to meet Type II (222) building requirements. Unprotected steel beams were found on the first floor landing of the East stair and in the garage attached to the building, violating the 2012 NFPA 101 standards.
The facility was found deficient in ensuring corridor doors resisted smoke passage, as required by NFPA 101. During a survey, it was noted that doors to the clinical social worker's office and medical equipment storage closet had transfer grilles, and a large storage room lacked a door. These issues were identified on the first and third floors.
A cognitively impaired resident was subjected to abuse by an LPN during medication administration, as captured on video surveillance. The LPN forcefully tilted the resident's head back, held their nose, and shoved a spoon into their mouth. Additionally, the LPN kicked the resident's wheelchair and pushed it against a table, locking it in place. A CNA present did not intervene or report the incident immediately. The facility's failure to protect the resident and ensure staff adherence to the abuse prevention care plan resulted in a deficiency citation.
Failure to Implement Care Plan Leads to Resident Harm
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident who required a two-person assist for bed mobility, transfers, and all activities of daily living. This deficiency was identified during an abbreviated survey, where it was found that staff did not implement the necessary interventions as per the resident's care plan. The resident, who had severe cognitive impairment and functional limitations, was involved in two separate incidents where staff failed to follow the care plan, resulting in harm. In the first incident, a Certified Nurse Aide found the resident on the floor and used a Hoyer lift alone to move the resident back into bed, contrary to the policy requiring two certified/licensed staff members for such transfers. The resident was found with a lump on the forehead, a swollen and deviated nose, and bleeding from the right nostril. Despite the resident's severe cognitive impairment and inability to communicate, the staff member did not call for help before moving the resident, which was against the facility's policy. In the second incident, another Certified Nurse Aide provided care to the resident alone, resulting in the resident bumping their head on the bedside table. This incident also violated the care plan, which required a two-person assist. The resident sustained a hematoma and a nosebleed, and was later diagnosed with a brain bleed, broken neck, and extensive facial fractures at the hospital. The Medical Examiner noted that the extent of the injuries was not consistent with the explanations provided, and the manner of death could not be determined.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in accordance with professional standards for food service safety. During the recertification survey, it was observed that food items in the kitchen refrigerators, freezers, and storage areas were not properly identified or dated. Specific items such as croissants, pulled chicken, meatballs, and various sauces were found without labels or dates. Additionally, staff members were observed not wearing hairnets or beard covers properly, and maintenance personnel entered the kitchen without appropriate hair coverings. The kitchen environment was also found to be unsanitary, with broken tiles, damaged baseboards, and dust accumulation in various areas. Further observations revealed that the pantry refrigerators on different floors had issues with temperature regulation and cleanliness. The third-floor pantry refrigerator was found to be at 50 degrees Fahrenheit, with open and unlabeled bottles, and a take-out food container with a resident's name dated from a previous month. The ice machines in the pantries were dirty, with hard water deposits noted. The Food Service Director acknowledged these issues and stated that there was a cleaning schedule in place, but the deficiencies in food handling and sanitation practices were evident during the survey.
Deficiencies in Positioning and Mobility Care
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with professional standards for three residents concerning positioning and mobility. Resident #16, who had a left-hand contracture, was not provided with a positioning device to manage their condition. Observations revealed that the resident's left hand was contracted into a fist with long fingernails curling inside, and there was no care plan or physician's orders addressing the contracture. The Registered Nurse Unit Manager acknowledged the oversight and stated that a rehabilitation screen request should have been sent earlier. Resident #60, who required a tilt-in-space wheelchair, was not positioned correctly, leading to unsafe postures such as leaning to the left and having their head unsupported. Observations showed the resident in various positions without proper support, and there was no documented guidance for staff on how to use the specialized wheelchair. Interviews with staff revealed a lack of awareness and education regarding the correct use of the wheelchair, and the Director of Rehabilitation admitted that the necessary instructions were not included in the care plan or provided to the staff. Resident #37, who was at risk for pressure ulcers, was not consistently provided with heel boots as ordered by the physician. Observations noted the absence of heel boots during multiple instances, and the Treatment Administration Record showed missing signatures for the application of the boots on several days. Staff interviews confirmed that the resident did not use heel boots, and there was no documentation of refusal by the resident. The Registered Nurse Unit Manager confirmed that the heel boots should have been in use and documented accordingly.
Environmental Deficiencies in Resident Areas
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on the 2nd and 3rd floors, as observed during a recertification survey. On the 3rd Floor Unit, issues included a broken handrail endcap, a pervasive strong odor of urine, a broken dresser, a ripped chair, stained shower room walls, stained community bathroom tiles, cracked floor molding, gouged sheetrock, and visibly soiled privacy curtains. Additionally, the Community room floor had visible dust and debris, and baseboard moldings were cracked and soiled with wax buildup. Similar issues were noted on the 2nd floor, where baseboard moldings were also cracked and soiled with wax buildup. Interviews with staff revealed systemic issues contributing to these deficiencies. The Director of Housekeeping acknowledged the need for baseboard replacements and cited insufficient staffing as a reason for the lack of scheduled terminal room cleanings. They also noted that air fresheners had been removed due to painting, contributing to the urine odor. The Director of Maintenance admitted to not being aware of the broken handrail endcap and stated that maintenance staff did not routinely enter resident rooms unless issues were reported. They also indicated that housekeeping staff might not have been trained to report environmental issues, and regular audits were not conducted. Resident feedback corroborated the observations, with complaints about the cleanliness of the community bathroom.
Failure to Provide Necessary Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene. Specifically, a resident who required extensive assistance with personal hygiene and was dependent on staff for showers and bathing was observed with long fingernails and a contracted left hand. The facility's policy required nail care as part of routine activities of daily living, and the resident's care plan included an intervention to trim nails weekly and as needed. However, observations revealed that the resident's fingernails were long, stained, and curling into their contracted left hand, indicating a lack of adherence to the care plan. Interviews with facility staff further highlighted the deficiency. A Certified Nurse Aide who provided care to the resident did not notice the long fingernails during their shift, and upon being shown the resident's fingernails, acknowledged that they were too long and should be clipped. A Registered Nurse Unit Manager also confirmed that the resident's fingernails were too long and needed to be trimmed to prevent them from digging into the palm of the resident's contracted hand. These observations and interviews demonstrate a failure to provide the necessary personal hygiene care as outlined in the resident's care plan and facility policies.
Failure to Develop Comprehensive Care Plans for Positioning and Mobility
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was developed and implemented for two residents concerning their positioning and mobility needs. Resident #16, who had a left hand contracture, did not have a care plan addressing this condition. Observations noted that the resident's left hand was consistently clenched in a fist, and interviews with staff confirmed awareness of the contracture but revealed that no care plan had been created to address it. The Registered Nurse Unit Manager acknowledged the absence of a contracture care plan and admitted that one should have been written. Resident #60, who used a specialized tilt-in-space wheelchair, also lacked a comprehensive care plan for positioning. Observations showed the resident in various states of improper positioning, such as leaning to one side with their head unsupported and feet dangling without footrests. Interviews with staff, including a Licensed Practical Nurse and a Certified Nurse Aide, indicated a lack of awareness and specific instructions regarding the use of the specialized wheelchair. The Director of Rehabilitation and the Director of Nursing both stated that the care plan should have included detailed instructions for the wheelchair's use, but no such documentation was found. The deficiency was further highlighted by the absence of documented education for direct care staff on the use of the tilt-in-space wheelchair. The Director of Rehabilitation mentioned that the Certified Nurse Aide Care Guide and a Positioning Care Plan should have provided necessary instructions, but these were not in place. The Registered Nurse Unit Manager admitted responsibility for developing and updating care plans and acknowledged the lack of a developed care plan for Resident #60's specific positioning needs.
Inadequate PPE Use by Housekeeping Staff Under Droplet Precautions
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, specifically in the use of Personal Protective Equipment (PPE) by housekeeping staff in a room under Droplet Precautions. On March 30, 2025, a housekeeper entered a room marked with a Droplet Precaution sign without wearing a gown and exited wearing gloves, which they did not remove or sanitize after leaving the room. This action was observed on video footage reviewed with the facility Administrator. Additionally, on April 1, 2025, another housekeeper entered the same room wearing a surgical mask instead of the required N-95 mask, as indicated by the Droplet Precaution sign. The housekeeper acknowledged the mistake, stating they forgot to change their mask. The Activities and Housekeeping Supervisor confirmed that all housekeeping staff were educated on transmission-based precautions and the proper use of PPE, including the requirement to wear N-95 masks and perform hand hygiene when exiting rooms with Droplet Precautions.
Non-compliance in QAPI Committee Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committees included the required attendance of the Medical Director or their designee, and the Infection Control Practitioner at quarterly meetings. Specifically, the Medical Director or their designee did not participate in three out of four QAPI meetings, and the Infection Control Practitioner was absent from two out of four quarterly meetings. This deficiency was identified through a review of the facility's QAPI policy and the attendance sheets for meetings held on specific dates, which showed the absence of signatures from the Medical Director and the Infection Control Practitioner. During an interview, the Administrator acknowledged the issue, stating that the previous Medical Director had attendance problems, and a new Medical Director was hired at the beginning of the year. Additionally, the Administrator noted that the Infection Control Practitioner had not been attending the QAPI meetings, but a new practitioner had been hired and attended the last two quarterly meetings. The facility's policy, last revised in June 2025, requires the participation of key personnel, including the Medical Director and Infection Control Practitioner, in the QAA committee, which was not adhered to, leading to this deficiency.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required by regulation. Specifically, on November 2, 2024, no RN was present during the 24-hour period. This deficiency was identified during a recertification survey conducted from March 30, 2025, to April 4, 2025. The facility's Minimum Nursing Staffing Plan, reviewed on January 15, 2025, documented the requirement for an RN to be staffed on all shifts. During interviews conducted on April 4, 2025, both the Director of Human Resources/Covering Staffing Coordinator and the Director of Nursing confirmed the absence of an RN on the specified date and acknowledged their awareness of the regulatory requirement for RN coverage.
Unprotected Steel Beams Found in Facility
Penalty
Summary
During a life safety survey, it was observed that the facility did not maintain all structural components to meet the requirements for a Type II (222) building construction. Specifically, unprotected steel beams were found on the first floor landing of the East stair and in the garage attached to the building, which is accessible from the first floor. These findings indicate a failure to comply with the construction type limitations as outlined in the 2012 NFPA 101 standards, which require complete automatic sprinkler protection for buildings of this type.
Plan Of Correction
Plan of Correction: Approved April 17, 2025 K 161- Automatic Sprinkler Protection I. IMMEDIATE CORRECTIVE ACTION: A licensed Contractor was hired to encapsulate the exposed, unprotected steel beams with the approved 2-hour NFPA material. II. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. In order to ensure full compliance of this standard throughout the facility, all beams were assessed. None were found deficient at this time. III. SYSTEMIC CHANGES: A Monthly Compliance Audit of affected/corrected beams will begin (MONTH) 2025. These monthly audits will continue for a period of 3 months with results reported by the Director of Maintenance to the facility QAPI Committee. Any negative findings will be immediately reported to the Director of Maintenance and corrected. IV. QAPI MONITORING: The findings of the above noted compliance audit will be reported to the facility Quality Assurance and Performance Improvement Committee monthly for 3 months by the Director of Maintenance. Any trends or concerns that may be identified will be discussed by the committee and any interventions will be implemented. The QAPI Committee will determine the need for ongoing reporting. Completion Date: 05/30/2025 Responsible Party: Director of Maintenance
Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that all corridor doors were designed to resist the passage of smoke, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the doors to the clinical social worker's office and the medical equipment storage closet were equipped with transfer grilles at the bottom, which is not permitted. Additionally, a large storage room on the first floor near the garage entrance was found to be lacking a door entirely. These deficiencies were noted on the first and third floors of the facility, and the Director of Maintenance acknowledged the issues during the survey.
Plan Of Correction
Plan of Correction: Approved April 17, 2025 K 353- Sprinkler System- Maintenance and Testing I. IMMEDIATE CORRECTIVE ACTION The 5-year internal pipe inspection of the sprinkler system was immediately scheduled with our vendor Sprinkler Company. The Maintenance Staff were educated to ensure that all required testing, inspection and maintenance was conducted on the facility's automatic sprinkler system. II. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. In order to ensure full compliance of this standard throughout this facility, the Director of Maintenance will review any additional required Automatic Sprinkler Testing to ensure it too meets all aspects of the NFPA Standard. All other Maintenance and Testing current and up to date. III. SYSTEMIC CHANGES: A monthly compliance audit will be completed to ensure that all required Sprinkler Maintenance and Testing are done. This audit will begin (MONTH) 2025 and continue for a period of 12 months. Any negative findings will be immediately reported to facility administrator and corrected. IV. QAPI MONITORING: The findings of the audit will be reported to the facility Quality Assurance and Performance Improvement Committee for 3 months by the Director of Maintenance. Any trends or concerns that may be identified will be discussed by the committee and any necessary interventions will be implemented. The QAPI Committee will determine the need for ongoing reporting. Completion date: 05/30/2025 Responsible Party: Director of Maintenance
Abuse Incident During Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, as evidenced by an incident involving a cognitively impaired resident during medication administration. Video surveillance captured a Licensed Practical Nurse (LPN) forcefully tilting the resident's head back, holding their nose, and shoving a spoon into their mouth. The LPN was also seen kicking the back wheel of the resident's wheelchair and pushing it against a table, locking it in position. This incident occurred in the dining room, where the resident was seated alone at a table. The resident, who was re-admitted with unspecified diagnoses, had a care plan in place to prevent abuse, which was not adhered to during this incident. The video footage showed the LPN's aggressive actions, including shoving the resident's wheelchair against a wall. A Certified Nurse Aide (CNA) present during the incident did not intervene or report the abuse immediately, although they later acknowledged witnessing the LPN's inappropriate behavior. The incident was brought to the attention of the facility's administration the following day when another CNA reported witnessing the LPN kicking the resident's wheelchair. This prompted a review of the video footage and subsequent investigation. The facility's failure to protect the resident from abuse and ensure staff adherence to the abuse prevention care plan resulted in a deficiency citation.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 No Plan of Correction is required. By copy of this notice received on (MONTH) 25, 2025, from the Metropolitan Area Office, this office is informing the facility Administrator and the CMS of the Immediate Jeopardy findings and Substandard Quality of Care. The facility employed corrective measures prior to the survey that removed the IJ identified on 02/26/2025. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance on 2/27/2025 and was in substantial compliance for this specific regulatory requirement at the time of this survey. The facility will continue our training, audits, and QAPI monitoring to ensure this deficient practice will not recur.
Removal Plan
- A full investigation was started after administration viewed the video.
- Staff that were on the unit during the incident were brought to the conference room.
- The three accused staff were suspended.
- Accused Licensed Practical Nurse #1 was terminated.
- Information about the incident was sent to the NYS Education Department and Office of Professionals.
- The name of Licensed Practical Nurse #1 is with local authorities with a case open and an open order of protection.
- The Abuse care plan was updated.
- The interdisciplinary team discussed the allegation of abuse with the resident.
- Attending Physician performed an assessment with no negative findings.
- Resident #1 was placed on 1:1 monitoring.
- The Director of Nursing called the family of Resident #1.
- All other residents were evaluated and assessed.
- Social workers began interviewing the residents to ensure they felt safe.
- Residents were instructed on how to report abuse or any concerns they might have.
- Residents were given the phone number for the Department of Health as well as the Ombudsman.
- Met with the Resident Council to ensure all residents are aware of how to report abuse.
- Interview with Resident Council president confirmed that they were all spoken with about abuse and how to report it.
- Residents were given business cards with phone numbers.
- All other staff have been educated on the importance of informing/reporting immediately and protecting the residents in their care.
- After incident in-service with a final complete 100% attendance.
- An Ad Hoc Quality Assurance Performance Improvement meeting was held.
- Suspension and termination, re-education for abuse prevention with a concentration on removal of resident and immediate reporting were discussed.
- Calling family with update was addressed.
- Dining room and feeding competencies were addressed.
- Another Quality Assurance Performance Improvement meeting and morning report continued the 1:1 monitoring, reviewed medication and care for resident.
What surveyors are citing around you — mapped
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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 214 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holmes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Putnam Ridge | 6 mi | ★★★★★ | 6 | 0 |
| The Grand Rehabilitation And Nursing At Pawling | 6.8 mi | ★★★★★ | 0 | 0 |
| The Paramount At Somers Rehab And Nursing Center | 11.1 mi | ★★★★★ | 21 | 1 |
| Waterview Hills Rehabilitation And Nursing Center | 11.3 mi | ★★★★★ | 0 | 0 |
| Salem Hills Rehabilitation And Nursing Center | 11.3 mi | ★★★★★ | 1 | 0 |
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