Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Center during CMS and state inspections, most recent first.
Surveyors identified a strong, unpleasant odor throughout the building on multiple occasions, which was confirmed by a Corporate RN. The facility's cleaning policy emphasizes maintaining a safe and hygienic environment, but the observed conditions did not meet these standards.
Two residents did not receive incontinence care for several hours, despite reporting the issue to a nursing assistant during lunch. The assigned NA was observed using her personal phone and attending to other residents, while another NA was redirected before completing care and did not inform others of the unmet needs. The facility's investigation, upon review, confirmed the neglect based on witness and resident statements.
Surveyors found that several dependent residents did not consistently receive scheduled showers or bed baths, with significant gaps in care and missing documentation. Interviews with residents, family, and staff, as well as review of care plans, revealed that showers were missed due to staff changes and lack of follow-through, and that there was no written policy for bathing frequency. The DON confirmed that expected care and documentation were not consistently provided.
The facility did not clarify physician orders for oral medications for residents with NPO status, resulting in documentation of oral medication administration during periods when residents were not to receive anything by mouth. Additionally, a newly admitted resident did not receive required CPAP equipment upon arrival, and necessary orders and care planning were not initiated before discharge. These actions and inactions were confirmed through record review and interviews.
The facility did not ensure that the pharmacist reported medication regimen irregularities for three residents with NPO orders, resulting in oral medications being ordered and documented as administered despite NPO status. The pharmacist's reviews did not identify or report these discrepancies, and the required notifications to the attending physician, medical director, and DON were not made.
The facility did not ensure accurate medical records and physician orders for several residents, including discrepancies in fall intervention documentation and the administration of oral medications to residents with NPO orders. Although leadership stated that medications were given via tube, the records indicated oral administration, and care plans did not match physician orders for fall prevention.
Two residents did not receive timely incontinence care, with one found in a soiled and disintegrated brief and exhibiting skin redness. Staff failed to communicate care needs, and documentation confirmed a new wound consistent with incontinence-associated dermatitis. Witness and resident statements verified the neglect.
A resident's care plan was not updated to include all current fall interventions, such as 1:1 supervision, floor mats, and bed placement, despite these measures being in place and ordered. The care plan only listed a low bed with a parameter mattress, and omissions were confirmed by the DON and a corporate RN.
A medication tube was found at the bedside of a resident, presenting an accident hazard due to inadequate supervision and failure to maintain a hazard-free environment. The medication was discovered on the nightstand during a survey and was removed after staff notification.
A nurse dropped a cup lid on the floor, picked it up, and proceeded to use it to serve a drink to a resident without replacing it, until prompted by a surveyor. The DON acknowledged the lapse in maintaining a sanitary eating environment, and the nurse involved admitted to not realizing the mistake at the time.
Surveyors observed unclean floors, full trash cans, and personal items obstructing housekeeping, along with stained ceiling tiles and an open attic trap door allowing hot air into the building. Multiple beds were left unmade due to a shortage of linens, with the linen closet found empty and staff confirming ongoing supply issues. The administrator verified these deficiencies during the walkthrough.
Several residents were found without access to fresh water or fluids at their bedside, with some reporting infrequent water delivery and having to wait until meals for drinks. Staff interviews confirmed that water and ice were not consistently provided as required, resulting in inadequate fluid intake for residents.
A resident was found without physician-ordered heel boots intended to prevent pressure ulcers. Upon inquiry, a NA was unable to explain the omission, later retrieving and applying the boots after confirming the resident's preference. The absence of the heel boots was confirmed by both the NA and the DON.
Multiple residents were found living in unsanitary conditions, including bathrooms with soiled briefs and dried substances, rooms with spilled food and fluids that attracted ants, and hallways littered with trash and sticky puddles. Staff and RNs acknowledged these issues, which persisted throughout the day and did not meet standards for a clean, homelike environment.
A resident reported and was observed receiving cold meals, with food temperatures measured below the facility's required standard. The resident stated that this was a common issue, especially at breakfast and dinner, and that food carts were left out before delivery, resulting in unpalatable and improperly heated meals.
Surveyors identified that two residents' CPAP masks were repeatedly left on bedside tables instead of being stored in designated plastic bags, as required for infection control. Another resident's catheter bag and tubing were found lying on the floor, and a clean linen cart was observed uncovered in a hallway. These incidents were confirmed by nursing staff and the IP Nurse, demonstrating failures to follow established infection prevention protocols.
A resident was left uncovered and exposed to passersby due to an open door and undrawn privacy curtain, with catheter tubing visible. An IP nurse entered the room without knocking and only addressed the resident's need for coverage after observing his exposed state.
Two residents did not receive bathing care according to their documented preferences for showers, with one receiving mostly bed baths instead of scheduled showers and another receiving only a few showers despite multiple opportunities and no documented refusals for most missed showers. Both residents' care plans indicated a preference for showers, which was not consistently honored.
A resident was given PRN Ativan orders that exceeded the 14-day limit without documented physician review or rationale, and non-pharmacological interventions were not attempted or documented before administering the medication, despite care plan requirements. The DON confirmed these lapses in both medication review and intervention documentation.
The facility did not follow care plan interventions for two residents: one was given PRN Ativan without documented non-pharmacological interventions for anxiety and psychosis, and another, who is visually impaired, did not consistently receive individualized activity adaptations or one-to-one engagement as outlined in her care plan. These deficiencies were confirmed through record review and staff interviews.
A resident with significant vision impairment was repeatedly observed in bed without stimulation or engagement, despite a care plan specifying adaptive activities and one-to-one visits. Activity participation records showed minimal involvement, and the Activity Director acknowledged the decline in participation had not been addressed.
Surveyors found that the facility did not follow physician orders and protocols for several residents, including failure to repeat a lab test for one resident with elevated ammonia, not implementing the hypoglycemia protocol for another resident with low blood glucose, and not administering medications on time for a third resident. These deficiencies were confirmed by facility leadership.
A resident did not receive the correct prescription reading glasses as ordered by an Ophthalmologist, despite having an eye exam and prescription. Instead, the resident was given glasses that did not match the prescribed specifications, resulting in continued difficulty seeing.
A mattress was observed lying on the floor in a resident hallway, in front of the mechanical room and kitchen/service hall entrance. Both a nurse aide and an RN acknowledged the mattress was a hazard and should not have been left there, as it could have caused a resident to fall.
Two residents were not offered sufficient fluids to maintain proper hydration, as evidenced by empty bedside cups and resident reports of difficulty obtaining water. The Administrator confirmed that these residents did not receive adequate hydration on the day observed.
A resident with poor dentition and ongoing oral discomfort did not receive routine dental services as required, despite being identified as needing dental care in their care plan and MDS assessment. The resident missed a scheduled dental appointment and was not rescheduled for future visits, resulting in no dental consults since admission, contrary to facility policy.
A resident who experienced multiple falls did not have properly completed post-fall neurological assessments, with missing signatures and incorrect or absent dates on the documentation. The administrator and DON confirmed that the required medical record entries were not completed accurately, resulting in a failure to maintain records according to professional standards.
A resident was unable to turn the over-bed light on or off independently because the light switch string was too short to reach. The DON confirmed the inaccessibility of the light string during observation.
The facility did not update care plans for several residents to include current fall prevention interventions, such as call light accessibility and non-skid equipment, and failed to accurately reflect dietary restrictions for a resident who could not tolerate cold or hot foods and beverages. These deficiencies were confirmed through record reviews and staff interviews.
A resident with a history of psychiatric disorders and physical aggression physically assaulted a nonverbal resident, resulting in facial injuries. Despite documented behavioral risks and interventions such as frequent monitoring and psychiatric consultation, the aggressive resident was able to harm another resident, indicating a failure to prevent resident-to-resident abuse.
Failure to Prevent and Address Pervasive Odors in Facility
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment by not preventing strong, unpleasant odors throughout the building. On two separate occasions, state surveyors observed and identified a pervasive odor during their initial entrance and subsequent rounds in the facility. The Corporate Registered Nurse confirmed the presence of the odor when interviewed by the surveyors and indicated awareness of the issue. The facility's own policy and procedure for resident room cleaning and floor care emphasized the commitment to providing a safe and hygienic environment, yet the observed conditions did not align with these standards.
Failure to Investigate and Address Alleged Neglect of Incontinence Care
Penalty
Summary
The facility failed to thoroughly investigate allegations of neglect involving two residents who reported not receiving incontinence care from 5:00 AM until 1:00 PM on the same day. The residents informed a nursing assistant (NA) during lunch tray delivery, who then enlisted another NA to assist with their care. The assigned NA was observed using her personal phone at the nurses' station and rounding on other residents, while another NA stated she was directed to the dining room before completing care for her last residents and did not notify others about the outstanding incontinence care needs. Review of the facility's investigation revealed that, despite the termination of the assigned NA and the investigation being initially marked as unverified, witness and resident statements did confirm the neglect occurred.
Failure to Provide and Document ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing, to residents who were dependent on staff for this care. One resident reported not receiving scheduled showers for extended periods, including an 11-day and a 7-day gap, and staff interviews confirmed lapses in providing showers due to shift changes and lack of follow-through. Documentation review showed that another dependent resident had no record of showers for an entire month and only one shower documented the following month, with missing documentation for both showers and bed baths on multiple days. The DON acknowledged the absence of a written policy regarding the frequency of showers or bed baths, although staff were expected to offer showers twice weekly and bed baths daily, with refusals to be documented. A third resident, also dependent for bathing, was reported by a family member as not receiving enough showers, and the DON was unable to find documentation of any refusals for this resident. Review of care plans and shower schedules confirmed that scheduled showers were not consistently provided or documented. These findings were based on resident and staff interviews, as well as review of care plans and documentation, and affected three residents in a facility with a census of 116.
Failure to Clarify NPO Medication Orders and Provide Timely Respiratory Equipment
Penalty
Summary
The facility failed to ensure continuity of care by not seeking clarification from physicians regarding oral medication orders for residents who were designated as NPO (nothing by mouth), and by failing to obtain necessary respiratory equipment for a newly admitted resident. For multiple residents, there were active NPO orders in place, yet the Medication Administration Records showed that oral medications were documented as administered during the NPO period. In some cases, the Director of Nursing (DON) stated that medications were given via tube, but the orders and documentation did not reflect this clarification, nor was there evidence of provider or pharmacy consultation as required by facility policy. Additionally, the facility did not conduct monthly reviews of orders by nursing staff, leaving them for physician signature without further verification. A newly admitted resident with a hospital order to continue home CPAP therapy for obstructive sleep apnea did not receive the required respiratory equipment upon arrival. The DON was uncertain if the CPAP order was included in the admission orders, and the equipment was not available until the following day. The resident was discharged back to the hospital before physician orders, diagnosis list, and care plan were initiated. These failures were confirmed through record review, staff interviews, and resident interviews, and were found to have the potential to affect a limited number of residents.
Failure to Report Medication Regimen Irregularities for NPO Residents
Penalty
Summary
The facility failed to ensure that the pharmacist reported medication regimen irregularities to the attending physician, medical director, and director of nursing, and that these reports were acted upon, as required by facility policy. Specifically, for three residents with NPO (nothing by mouth) orders, the pharmacist did not identify or report discrepancies where oral medications were ordered and documented as administered, despite the NPO status. The facility's policy required monthly drug regimen reviews, including review of the medical chart and reporting of any irregularities, but these steps were not followed for the affected residents. For the residents in question, orders and medication administration records showed that oral medications were prescribed and recorded as given during periods when the residents were under NPO orders. In interviews, the pharmacist stated that discrepancies would be reported if found, but no such discrepancies were indicated in the medication regimen reviews for these residents. The DON reported that medications were given via tube and that nursing staff were aware of the NPO status, but the documentation and pharmacist review did not reflect or address the route discrepancies. This failure was identified through record review and staff interviews, affecting three residents out of a facility census of 116.
Inaccurate Medical Records and Medication Administration for NPO Residents
Penalty
Summary
The facility failed to maintain accurate and consistent medical records and physician orders for multiple residents, specifically regarding fall interventions and medication administration routes for residents with NPO (nothing by mouth) orders. For one resident, there was a discrepancy between the care plan and physician orders for fall interventions, with the care plan listing a low bed parameter mattress while the physician orders included 1:1 supervision and floor mats, but no order for a low bed. Additionally, this resident had an active NPO order, yet the Medication Administration Record (MAR) documented the administration of several oral medications over a period of months, despite the NPO status. Two other residents with NPO orders also had MARs indicating the administration of oral medications during their NPO periods. In both cases, the DON reported that medications were given via tube and that nursing staff were aware of the residents' NPO status, but the documentation did not reflect the correct route of administration. These inconsistencies in documentation and failure to accurately follow and record physician orders for both fall interventions and medication administration routes were confirmed by facility leadership during the survey.
Failure to Provide Timely Incontinence Care Resulting in Neglect and Skin Breakdown
Penalty
Summary
The facility failed to protect residents from neglect and verbal abuse, as evidenced by two residents not receiving incontinence care for an extended period. Both residents reported to a nurse aide that they had not received incontinence care since early morning, and care was not provided until after lunch. The assigned nurse aide was observed using her personal phone at the nurses' station and did not communicate the residents' needs to other staff. Witness and resident statements confirmed the neglect, despite the initial facility investigation being unverified. Further review revealed that one resident's spouse found the resident in a soiled and disintegrated brief, with the resident exhibiting redness in the groin area. A nurse was observed cleaning the resident and expressed anger about the situation. The resident's spouse noted that the resident rarely had skin issues prior to admission. An LPN later found the resident without a brief, with a strong urine odor and pieces of the brief on the floor, and had to request housekeeping assistance. Documentation confirmed a new in-house wound described as incontinence-associated dermatitis.
Failure to Revise Care Plan for Fall Interventions
Penalty
Summary
The facility failed to revise the care plan for a resident regarding fall interventions. Observation revealed that the resident was in a low bed with fall mats on the right side and the left side of the bed against the wall, while receiving 1:1 supervision as ordered. Orders were in place for 1:1 supervision and floor mats on the right side of the bed for both day and night shifts, but there were no orders for a low bed with a parameter mattress. The resident's care plan only included a low bed with a parameter mattress as a fall intervention, and did not document the use of floor mats, the bed against the wall, or 1:1 supervision. These discrepancies were confirmed by the DON and a corporate RN.
Medication Left at Bedside Creates Accident Hazard
Penalty
Summary
A deficiency was identified when a tube of Clotrimazole & Betamethasone cream, a medication, was observed at the bedside of a resident. This observation was made during a facility survey, and the medication was found on the resident's nightstand. The presence of medication at the bedside constitutes an accident hazard and indicates a failure to ensure the environment was free from such hazards and that adequate supervision was provided to prevent accidents. The incident was discovered as a random opportunity during the survey, and the medication was subsequently removed after staff were notified.
Failure to Maintain Sanitary Meal Service Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident during meal service. A registered nurse was observed dropping a cup lid onto the dining room floor, picking it up, and placing it on the counter before filling the cup with ice and a drink. The cup and lid were then handed to a nurse aide, who placed the lid onto the cup and served it to a resident. This action occurred without replacing the contaminated lid until prompted by the surveyor. The Director of Nursing acknowledged the failure to maintain a sanitary eating environment, and the registered nurse involved admitted to not realizing the error until after the fact.
Failure to Maintain Cleanliness, Linen Supply, and Environmental Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations during a survey. Floors throughout the facility were found to be cluttered with paper, dust, and dried liquid spills, and trash cans were full. Personal items were left on the floor in some rooms, preventing housekeeping from sweeping. The facility's auto scrubber was not operational, contributing to the unclean conditions. Specific rooms were identified as being in particularly poor condition. Additionally, two ceiling tiles outside the activity room were stained and needed replacement, and a large ceiling trap door to the attic near the nurses' station was left open, allowing hot air to enter the facility after maintenance work. Several beds in one hallway were observed to be unmade due to a shortage of linens, as confirmed by a nurse aide and the administrator. The clean linen closet was found to be empty of fitted sheets, flat sheets, and blankets, and the administrator acknowledged that the laundry was working to address a backlog. These conditions were confirmed by both staff and the administrator during the survey.
Failure to Provide Sufficient Fluids to Maintain Hydration
Penalty
Summary
Surveyors observed that several residents did not have access to fresh water or fluids at their bedside during a walkthrough. Specifically, residents in multiple rooms either had empty water cups, only a small amount of warm water, or no water at all. One resident was seen finishing a meal without any drink provided, and staff confirmed that the resident had no drink with the meal. Another resident requested ice and stated that fresh water or ice had not been provided since the previous night, with her cup remaining empty. Additional residents also reported infrequent water delivery, indicating they often had to wait until meal times for fluids. Staff interviews revealed inconsistencies in the routine for passing water and ice. A nurse aide stated that water and ice are usually passed every shift, with meals, and as needed, but admitted she had not had time to do so on the day of the survey. The administrator and another nurse aide confirmed that residents needed fresh water and/or ice at the time of the observation. These findings demonstrate a failure to consistently offer sufficient fluid intake to maintain proper hydration and health for residents.
Failure to Follow Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
Surveyors observed that a resident did not have heel boots on as ordered by the physician, which are intended to help prevent pressure ulcers. During the observation, a nurse aide was questioned about the absence of the heel boots and stated she was unsure, as she had only recently started working on that hall. The nurse aide then retrieved the heel boots from under the sink and, after confirming with the resident that she wanted them on, placed them on her. It was confirmed by both the nurse aide and the Director of Nursing that the resident was not wearing the heel boots as per the physician's order at the time of the observation.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean, comfortable, and homelike environment for its residents. In one case, a resident's shared bathroom contained three soiled briefs, four articles of clothing, and a brown, dried substance on the floor and commode seat. The resident stated that neither they nor their roommate used the bathroom, attributing the mess to neighboring residents, and described the bathroom as consistently dirty. The Infection Preventionist confirmed the unsanitary condition of the bathroom during the survey. In another room, a resident's floor was found to have spilled cereal and dried fluid spots in the morning, which remained uncleaned throughout the day despite multiple observations. The Regional Resource RN agreed that the dirty floors did not meet standards for a clean, homelike environment. Additionally, another resident's room was observed to have food on the floor with ants present, and this condition persisted throughout the day. The Regional Resource RN again confirmed the lack of cleanliness. In the facility's north hallway, surveyors found trash and debris, including straw and plastic wrappers, scattered along the floor, as well as a sticky, dried puddle near the nurses' station. Both the RN and other staff acknowledged the presence of trash, debris, and the sticky puddle, confirming the ongoing failure to maintain a clean and safe environment.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and at a safe, appetizing temperature for at least one resident. During observation, a resident was seen picking at their breakfast and reported that the food was cold and that this was a frequent occurrence, particularly at breakfast and dinner. The resident indicated that food carts were left out before being delivered, contributing to the issue. Upon request, food temperatures were measured on a tray ready for delivery and found to be below the facility's standard of at least 120°F, with oatmeal at 112°F, hash-browns at 86.2°F, and biscuits with gravy at 105.5°F. The Culinary Manager confirmed that these temperatures did not meet the required standard at the time of delivery.
Infection Control Lapses in Equipment and Supply Storage
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Two residents with Continuous Positive Airway Pressure (CPAP) machines were found to have their CPAP masks stored improperly on bedside tables, outside of the provided plastic storage bags, during several observations throughout the day. Both residents confirmed that this was their usual practice, and the Regional Resource Registered Nurse acknowledged that the masks should have been stored in the plastic bags as per infection control protocol. Additionally, another resident's catheter bag and tubing were observed lying on the floor next to the bed, a situation confirmed by a Registered Nurse. Furthermore, a clean linen cart was found uncovered in a hallway, which was also confirmed by the Infection Prevention Nurse. These observations indicate lapses in maintaining proper storage and handling of medical equipment and supplies, directly contravening infection control standards.
Resident Dignity Compromised Due to Lack of Privacy and Failure to Knock
Penalty
Summary
A deficiency occurred when a resident was found lying in bed uncovered, with his buttocks exposed and catheter tubing visible, while his door was open and privacy curtain not drawn, leaving him exposed to anyone passing by. The Infection Prevention (IP) Nurse was present in the hallway and confirmed the resident's exposed state. The IP nurse entered the resident's room without knocking and asked if the resident was cold, to which he responded affirmatively and requested assistance to be covered. The IP nurse later acknowledged that she did not knock before entering the room.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident choice regarding bathing preferences for two residents reviewed for Activities of Daily Living (ADL). One resident, who preferred showers over bed baths, reported only receiving one shower per week despite being scheduled for two. Documentation over a 30-day period showed that this resident received only three showers and seventeen bed baths or sponge baths, contrary to her stated preference and care plan. The administrator confirmed that the resident was not receiving ADL care according to her preferences. Another resident, with a history of CVA, left hemiplegia, anoxic brain injury, craniotomy, spinal stenosis, myelopathy, confusion, impaired mobility, and weakness, also expressed dissatisfaction with the bathing process and reported not consistently receiving scheduled showers. Review of records indicated that out of seventeen opportunities, the resident received only four showers, with four documented refusals and nine instances where bed baths were given without any refusal noted. The administrator confirmed that this resident's preference for showers, as documented in the care plan, was not being met.
Failure to Limit PRN Psychotropic Medication and Attempt Non-Pharmacological Interventions
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure a resident was free from chemical restraints. Specifically, a resident was prescribed PRN Ativan orders that extended beyond the 14-day limit without documented physician or practitioner review and rationale for continuation. The resident received multiple PRN Ativan orders, each lasting longer than 14 days, and there was no evidence that these orders were appropriately reviewed or justified as required. Additionally, the facility did not attempt or document non-pharmacological interventions prior to administering PRN Ativan on several occasions, despite the resident's care plan indicating that such interventions should be attempted for mood and behavior concerns. The Medication Administration Record did not track these interventions, and progress notes only documented the administration of medication in response to symptoms such as anxiety or psychosis, without reference to non-pharmacological measures. The DON confirmed the lack of documentation and acknowledged that non-pharmacological interventions were not attempted or recorded as required.
Failure to Implement Care Plans for Medication and Activities
Penalty
Summary
The facility failed to implement care plan interventions for two residents, resulting in deficiencies related to medication administration and activity engagement. For one resident with a history of anxiety, bipolar disorder, psychosis, and recent admission from a long-term psychiatric hospital, the care plan required staff to attempt non-pharmacological interventions before administering PRN Ativan. However, on multiple occasions, the medication was given without evidence that these interventions were attempted, as confirmed by both documentation review and the Director of Nursing. Progress notes and the Medication Administration Record did not reflect any non-pharmacological measures being used prior to medication administration on the specified dates. Another resident, who is highly visually impaired and at risk for limited engagement, had a care plan that included specific interventions such as one-to-one visits, reading the daily chronicle, and assistance with adaptive equipment for activities. Review of activity participation records over several months showed that the resident participated in group activities only six times and was not regularly receiving the individualized interventions outlined in the care plan. The Activity Director confirmed that these interventions were not consistently provided and acknowledged missing the decline in the resident's participation. Both cases demonstrate that the facility did not follow the individualized care plans developed to meet the residents' needs. The lack of implementation of non-pharmacological interventions before administering PRN medication and the failure to provide planned activity adaptations and engagement opportunities were confirmed through record reviews and staff interviews. These actions and omissions led directly to the cited deficiencies.
Failure to Provide Activities Program Meeting Resident Needs
Penalty
Summary
The facility failed to provide a program of activities that met the needs and interests of a resident with highly impaired vision. Multiple observations over several days showed the resident lying in bed, often in a dark room, with no television or radio on and no other forms of stimulation. The resident was observed talking to herself and holding a cup, with no evidence of engagement in activities. The resident's care plan included specific interventions such as offering room visits for socialization, reading the daily chronicle, providing music, and using adaptive techniques to enable participation in activities. However, these interventions were not consistently implemented. A review of the resident's activity participation records over several months revealed minimal participation in group activities and a lack of regular one-to-one visits or assistance with adaptive activities as outlined in the care plan. The Activity Director confirmed that the resident was not on a one-to-one visit schedule and acknowledged a decline in the resident's participation, which had gone unnoticed. The resident's Minimum Data Set indicated that participation in activities and social engagement were very important to her, yet these preferences were not being met.
Failure to Follow Physician Orders and Timely Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders and protocols for multiple residents. For one resident, an elevated ammonia level was identified, and the physician ordered an increase in Lactulose and a repeat ammonia level in one week. However, the repeat ammonia level was not completed as ordered. Another resident experienced a documented hypoglycemic event with a blood glucose level of 47, but the hypoglycemia protocol, which included specific interventions and monitoring, was not followed as per the physician's orders. The resident's care plan included instructions to follow the hypoglycemia protocol, but documentation did not reflect that these steps were taken. Additionally, a third resident reported not receiving medications on time, and record review confirmed that several medications were either not administered or were given outside the facility's policy window for timely administration. These included oral medications for saliva balance, pancrelipase, cetirizine, prednisone, and insulin, with some doses missed or significantly delayed. The facility administrator and a regional resource RN confirmed these findings, acknowledging that physician orders and protocols were not followed as required.
Failure to Provide Correct Prescription Glasses
Penalty
Summary
The facility failed to ensure that a resident received the correct prescription reading glasses as ordered by an Ophthalmologist. The resident reported that, despite an eye examination and prescription for glasses provided six months prior, she had not received the prescribed glasses and was instead given a pair that did not allow her to see well. Record review confirmed the resident's last Ophthalmologist appointment and the specific prescription for reading glasses. Staff interviews further verified that the resident was not provided with the correct prescription glasses as ordered by the Ophthalmologist.
Mattress Left in Hallway Creates Accident Hazard
Penalty
Summary
A mattress was found lying on the floor in the north hallway, a resident area, in front of the mechanical room and the entrance to the kitchen/service hall at approximately 7:30 AM. This observation was made during a survey and was acknowledged by both a nurse aide and a registered nurse, who confirmed that the mattress should not have been left there. Both staff members recognized that the mattress constituted a hazard and that a resident could have fallen over it. The facility census at the time was 117.
Failure to Provide Adequate Hydration
Penalty
Summary
Surveyors found that the facility failed to provide sufficient fluid intake to maintain proper hydration and health for two residents. One resident reported difficulty obtaining water, and repeated observations throughout the day revealed that the disposable cup at the bedside remained empty. Another resident stated that staff would not always provide water and sometimes told the resident it was unnecessary; observations also showed the bedside cup was empty at multiple times during the day. The Administrator confirmed that both residents had not received proper hydration on the day in question.
Failure to Provide Routine Dental Services to Medicaid Resident
Penalty
Summary
The facility failed to provide routine dental services to a Medicaid-funded resident who was identified as being at risk for oral health problems due to poor dentition. The resident reported having only three teeth, with the upper tooth causing occasional pain and difficulty chewing. Despite a care plan noting the presence of obvious caries and the need for dental consults or referrals, there was no evidence in the medical record that any dental consults had been obtained since the resident's admission. The resident's MDS assessment also indicated the presence of obvious or likely cavities or broken natural teeth. Interviews and record reviews revealed that the resident was scheduled to be seen by the facility's dental provider but was not seen as planned. After missing the scheduled appointment, the resident was not placed back on the dental provider's list for subsequent visits, despite the provider visiting the facility every three months. The facility's policy requires annual oral inspections and routine dental care, but these services were not provided to the resident as required.
Incomplete and Improperly Authenticated Neurological Assessments After Resident Falls
Penalty
Summary
A review of the electronic health record revealed that a resident who had experienced seven falls during their stay did not have properly completed post-fall neurological assessments. Specifically, one assessment scanned into the resident's health record was missing correct dates and lacked the nurse's signature in eight instances. For a fall that occurred at 6:00 PM, the neurological assessment form was missing all four signature slots for the 30-minute checks and all four signature slots for the hourly checks. Additionally, the hourly checks that occurred after midnight were not dated to reflect the correct day the assessments were performed. The administrator confirmed that the neurological assessments were not signed or dated at the required times. The DON also verified that the original form was not completed accurately. These findings indicate that the facility failed to maintain medical records in accordance with accepted professional standards, specifically regarding the documentation and authentication of post-fall neurological assessments for the resident.
Failure to Provide Accessible Over-Bed Light Controls
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs by not ensuring that the over-bed light could be turned on and off by the resident at will. During an interview and observation, the resident reported being unable to reach the light switch string, which was found to be only about an inch long and out of reach. The Director of Nursing confirmed during an observation that the light string was not accessible to the resident. This deficiency was identified through resident and staff interviews and direct observation.
Failure to Revise Care Plans for Fall Prevention and Dietary Restrictions
Penalty
Summary
The facility failed to revise care plans to reflect current interventions for fall prevention and dietary restrictions for four residents. For three residents, the care plans did not include updated fall prevention measures that had been implemented, such as ensuring the call light was within reach, adding non-skid strips to the bed, using a dumped wheelchair, and providing non-skid footwear. These omissions were identified during record reviews, which showed that the care plans were not updated to include these specific interventions. Additionally, for one resident with dietary restrictions prohibiting cold foods and drinks, the care plan did not accurately reflect the resident's inability to tolerate very cold or hot beverages or foods. The resident's diet order specified no cold food or drinks, but the care plan did not address the restriction on hot items, and the resident continued to receive soups, coffee, tea, and hot chocolate. These findings were confirmed by facility staff during interviews.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a nonverbal resident from physical abuse by another resident. The incident involved a resident with a history of physical aggression, psychiatric disorders, and medication noncompliance, who was witnessed hitting a nonverbal resident multiple times in the face. The assaulted resident sustained visible swelling and bruising on the left side of the face, was grimacing, and could not be consoled. The resident was sent to the emergency department for evaluation, where no acute injuries were found, and later returned to the facility at baseline mood and interaction. Prior to this incident, the aggressive resident had a documented history of behavioral issues, including a previous episode of physical aggression toward another resident. The care plan for this resident identified multiple risk factors such as cognitive deficits, psychiatric diagnoses, poor impulse control, and a pattern of challenging behaviors. Interventions included frequent monitoring, behavioral assessments, and attempts to manage the resident’s environment and triggers. Despite these measures, the resident continued to refuse medication and exhibited escalating behaviors. The facility's records indicate that staff were aware of the resident’s behavioral risks and had implemented interventions such as visual checks and psychiatric consultations. However, these interventions did not prevent the physical abuse of the nonverbal resident. The facility was unable to provide further information regarding the incident beyond the immediate response and care provided to both residents involved.
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 72 citations issued within 25 miles in the last 12 months — including the 1 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
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 Hurricane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Teays Valley Center | 0.8 mi | ★★★★★ | 17 | 0 |
| Cabell Healthcare Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Riverside Valley Of Journey | 11.3 mi | ★★★★★ | 2 | 0 |
| Valley Center | 13.3 mi | ★★★★★ | 2 | 0 |
| Dunbar Center | 14 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Putnam 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.