Putnam Nursing & Rehabilitation Center

Inspectors wroteBased on record review and interview conducted during an abbreviated survey (NY00344683), the facility failed to ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents. Specifically, staff did not implement interventions as per the care plan for Resident #2 who required 2-person assist for bed mobility, transfers and all activities of daily living. There were two (2) separate incidents that occurred with different staff each time. The first incident occurred on [DATE], when Certified Nurse Aide #3 found Resident #2 on the floor in the residents' room and used a Hoyer lift (a mechanical lift device) by themselves to move the resident back into their bed. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 3/30/2025 to 4/04/2025, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 2 of 2 resident floors (2nd and 3rd Floors) during observation of the environment. Specifically, the 3rd Floor Unit had a broken handrail endcap, an ongoing foul, pervasive, strong odor of urine, a broken dresser and a ripped chair were observed in room [ROOM NUMBER], the shower room walls were stained, the community unit bathroom tiles were stained, floor molding was cracked, sheetrock had a gouge, the Community room floor had visible dust and debris, privacy curtains in resident rooms were visibly soiled, and some base board moldings were cracked and soiled with wax build up. [...]

Inspectors wroteBased on interview and record review during the recertification survey from 3/30/2025 to 4/4/2025 the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 3 residents (#16, #60, and #37) reviewed for Positioning and Mobility. Specifically, Resident #16 was not provided a positioning device for their left-hand contracture (shortening and hardening of muscles often leading to deformity and rigidity of joints), Resident #60 was not positioned correctly in their wheelchair, and Resident #37 was not provided positioning devices they needed for comfort and positioning.

Inspectors wroteBased on observation and interviews conducted during the recertification survey from 3/30/2024 to 04/04/2025, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, food items were not properly identified and dated in the kitchen refrigerators, freezers, food storage areas and unit pantry refrigerators. Staff in the kitchen were observed without hairnets worn properly and beard covers. Areas in the kitchen were found with broken tiles, damaged baseboards, and dirt/dust.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey from 3/30/2025 to 4/4/2025, the facility did not ensure a person-centered comprehensive care plan was developed and/or implemented for 2 of 3 residents (#16 and #60) reviewed for Positioning and Mobility. Specifically, there was no documented evidence that a care plan was developed for Resident #16's left hand contracture (shortening and hardening of muscles often leading to deformity and rigidity of joints), or for Resident #60's positioning in their specialized wheelchair.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 3/30/2025 to 4/4/2025, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 1 of 4 residents (Resident #16) reviewed for Activities of Daily Living. Specifically, Resident #16, who required extensive assistance with personal hygiene and was dependent with showers/ bathing, was observed during multiple observations with long fingernails and a left-hand contracture (shortening and hardening of muscles often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 3/30/2025-4/4/2025, the facility did not ensure that a Registered Nurse was on duty for at least 8 consecutive hours a day, 7 days a week for one of 26 weekend days reviewed from 10/5/2024 through 12/31/2024, and daily staffing reviewed from 3/1/2025 through 4/3/2025. Specifically, no Registered Nurse worked during the 24-hour period on 11/2/2024.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 3/30/2025 to 4/04/2025, the facility did not ensure the Quality Assurance & Performance Improvement and Quality Assessment & Assurance committees consisted at a minimum of the Medical Director, or their designee, and the Infection Control Practitioner attendance quarterly meetings. Specifically, the Medical Director or designee had not participated in Quality Assurance & Performance Improvement meetings for three out of the four meetings and the Infection Control Practitioner did not participate in two out of four Quarterly meetings as required.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from 3/30/2025 to 04/04/2025, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections. Specifically, housekeeping staff did not wear the appropriate Personal Protective Equipment when going inside the room of a resident on Droplet Precautions.

Inspectors wroteBased on record reviews and interviews conducted during an abbreviated survey (NY00373527) conducted, the facility did not ensure that a resident (Resident #1) was free from abuse. This was evident for one (1) of three (3) residents reviewed for abuse. Specifically, on 2/26/2025 at 5:00 PM video surveillance recorded Licensed Practical Nurse #1 abusing Resident #1, who is cognitively impaired, during a medication administration. Licensed Practical Nurse #1 is seen forcefully tilting the resident's head back and holding the resident's nose, while shoving a spoon in their mouth. Licensed Practical Nurse #1 was also seen kicking the back large wheel of the wheelchair that the resident was sitting in and pushing the wheelchair against a table, locking it in position. This resulted in no actual harm that posed an Immediate Jeopardy past non-compliance for Resident #1.

Inspectors wroteBased on observation, and interview conducted during the Recertification Survey from 12/13/2022 to 12/19/22, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with accepted professional principles and included the appropriate accessory and cautionary instructions, and an expiration date when applicable for 1 of 3 medication carts reviewed for medication storage. Specifically, Medication Cart # 1 contained both an open Novolog insulin pen and an open multidose bottle of Lispro insulin not labeled with a resident's name and/or date opened.

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 12/13/2022-12/19/2022 the facility did not ensure that an infection prevention and control program was established and maintained to prevent the development and transmission of COVID-19. Specifically one LPN #4 (Licensed Practical Nurse) did not use appropriate Personal Protective Equipment (PPE) including eye protection and gowns when providing patient care for two of five residents (Residents #66, #28,) who were COVID 19 positive.

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident was provided with the necessary care and services to ensure that the resident's ability to communicate their needs to staff was available. This was evident for 1 of 1resident (Resident #41) reviewed for communication. Specifically, Resident #41 spoke Polish as her primary language and had little understanding of the English language. The resident was not provided with a Polish translator as indicated in the resident's Comprehensive Care Plan Additionally, the staff did not know how to access the language phone line to obtain a translator.

Inspectors wroteBased on observations, an interview, and record reviews conducted during the Recertification Survey, it was determined that for one of one (Resident #104) reviewed for Acidents the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, a resident with a diagnosis of Parkinson Disease (a progressive neurological disease marked especially by tremor of resting muscles, rigidity and slowness of movement) was being pushed in a wheelchair by staff in an unsafe manner.