Lutheran Center at Poughkeepsie Inc

Inspectors wroteBased on observation, record review and interview conducted during survey, the facility failed to ensure each resident received adequate supervision and consistent with resident needs to prevent accidents for two (2) of four (4) residents (Resident #9, Resident #8) reviewed for accidents. Specifically, on 03/25/2026, Resident #9 left the facility though an alarmed fire door, staff did not respond for over three (3) minutes to the alarm, and the resident fell in the parking lot and was found bleeding with abrasions to their forehead, nose and knees. 2) Resident #8 was at high risk for falls and care planned to be in the dining room in view of staff. On 04/07/2026, the resident fell in the dining room and sustained a large bump on the forehead while the certified nurse aide providing supervision was looking at their phone and out the window. [...]

Inspectors wroteBased on observations, interviews, and record reviews during the survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of three (3) residents (Resident #147) reviewed for Urinary Tract Infection, one (1) of three (3) residents (Resident #13) reviewed for Position/Mobility, and one (1) of one (1) resident (Resident #12) reviewed for Anticoagulation. Specifically, 1) Resident #147 was exhibiting symptoms of a urinary tract infect, urine samples for testing were not collected as ordered and the antibiotic was started prior to the sample collection; 2) Resident #13 was evaluated and waiting for a fitting for new orthotics which was delayed due to untimely follow up by the facility; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (1) out of three (3) residents (Resident #1) reviewed for pressure ulcers. Specifically, on 08/20/2025, Resident #1 was assessed as having a blanchable area of moisture associated skin damage to their coccyx/buttocks, was dependent for bed mobility, had no interventions implemented and was later diagnosed with an unstageable pressure ulcer. Additionally, Resident #1 had functional limitations with an order to have their feet offloaded while in bed, which was not consistently done resulting in a deep tissue injury to the resident's right heel. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (2625335), the facility did not ensure assessments accurately reflected the resident's status for 1 out of 3 residents (Resident #1) reviewed for assessments. Specifically, Resident #1 had a Physical Therapy evaluation in the facility on 08/22/2025 and was found to require maximum assistance for bed mobility. However, an admission Minimum Data Set, dated [DATE] documented Resident #1 as dependent for bed mobility on their functional assessment.

Inspectors wroteBased on record review and interviews during an abbreviated survey (2625335), the facility administrator did not ensure they used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, during an abbreviated survey, the facility did not provide requested facility policies to the Surveyor on-site. The Director of Nursing stated there is no documented facility policy for the following: Braden scale assessments, skin observation, admission assessments or a Minimum Data Set Assessment policy.

Inspectors wroteBased on observation, record reviews, and interviews during an abbreviated survey (NY00345910, NY00358013), the facility did not ensure the residents right to be free from abuse for 2 out of 3 residents (Residents #1 & #3) reviewed for abuse. Specifically, (1) on 6/19/2024, Certified Nurse Assistant #1 was observed on video surveillance engaging in a verbal altercation with Resident #1 and taunting them in the dining room. Certified Nurse Assistant #1 was also observed engaging in a shoving match at a table in the dining room with Resident #1. Resident #1 and Certified Nurse Assistant #1 later engaged in a physical altercation at the nurse's station where Resident #1 was seen grabbing Certified Nurse Assistant #1 by their shirt and Certified Nurse #1 and Resident #1began tussling; [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00345910, NY00333580, NY00358013) the facility did not ensure the report of the results of an investigation to the New York State Department of Health in accordance with State law within 5 working days of the incident or report an allegation of abuse within the regulatory timeframe for 3 of 4 residents (Resident #1, #2, #3) reviewed for abuse. Specifically, (1) On 6/19/2024 Certified Nurse Assistant #1 was observed on video surveillance engaging in a verbal altercation and the pushing and pulling of a table back and forth with Resident #1. Review of the 5-day investigative conclusion submission revealed it was not submitted to the New York State Department of Health until 7/25/2024; (2) On 2/13/2024 Resident #2 reported alleged inappropriate contact by Certified Nurse Assistant #3. [...]

Inspectors wroteBased on observations and interviews during an abbreviated survey (NY00333580), the facility did not ensure that each residents had the right to a dignified existence and each resident was cared for in a manner and environment that promoted maintenance or enhancement of their quality of life. This was evident for 1 of 3 residents (Resident #4) reviewed for dignity. Specifically, during an observation on Unit 1 South on 1/6/2025 Certified Nurse Assistant #2 was standing over Resident #4 while assisting them with their meal in the alcove in the hallway.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00345910, NY00358013), the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 2 out of 3 residents (Resident #1, #3) reviewed for care planning. Specifically, (1) On 6/19/2024 Certified Nurse Assistant #1 was observed on surveillance footage engaging in a verbal altercation and taunting Resident #1. Certified Nurse Assistant #1 and Resident #1 then engaged in a physical tussle at the nurse's station. Review of Resident #1's care plans revealed they did not have an abuse, victim, or potential victim care plan initiated until after the incident on 6/19/2024; [...]

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity in an environment that promotes maintenance of their quality of life for 2 of 4 residents (Residents #49, and #116) reviewed for dignity. Specifically, 1. Resident #49 was observed on several occasions wearing a food-stained gown; 2. signs that were visible to staff and visitors detailing how to feed Resident #116 were placed above the bed.

Inspectors wroteBased on record review and interviews conducted during the recertification survey process from 1/30/2024 through 2/6/2024, the facility did not ensure that all alleged violations involving abuse were reported no later than 24 hours even if the events did not result in serious bodily injury, to other officials (including to the State Survey Agency) in accordance with State law through established procedures. Specifically, the facility did not report 3 resident-to-resident altercations involving Resident #126 as the victim.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the recertification and abbreviated surveys (NY00326854), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two of three residents (Resident # 24 and #62) reviewed for accidents. Specifically, 1. staff did not ensure that Resident #24 received the correct meal texture based on physician order; and 2. the plan of care for Resident #62 was not implemented resulting in the resident sustaining a fall with major injury.

Inspectors wroteBased on observations, record review and interviews on a recertification survey 01/30/24-02/06/24 the facility did not ensure that drugs and biologicals were stored in locked compartments under temperature controls, and only permitted authorized personnel to have access to the keys. Specifically, 8 blister packs of medicines were left on a table in the manager's unlocked office on a unit with wandering residents.

Inspectors wroteBased on observation and interview conducted during a recertification survey and abbreviated survey (NY00324752), the facility did not ensure that food contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with standards for food service safety. Specifically (1) dirty and dusty fan blowing on clean dishes that were drying, (2) ovens and stove had caked on particles and grease, (3) dirty and dusty ceiling tiles and vents with dark markings on them, and (3) kitchen had a foul odor. Chapter 1 Sub-Part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated; non-food contact surfaces are to be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris; [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey 1/30/24-2/6/24, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed handling clean linen on a cart with dirty gloves in 2 of 3 rooms, clean PPE (personal protection equipment) carts were located on the inside of contact isolation rooms.

Inspectors wroteBased on record review and interview during the recertification survey conducted 01/30/24-2/6/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #49) reviewed. Specifically, there was no documented evidence Resident #49 was offered, declined, or educated on the pneumococcal immunization.

Inspectors wroteBased on observation and staff interview during the recertification survey and abbreviated survey (NY00324752) the facility did not ensure that essential equipment was maintained in safe operating condition. Specifically, there were missing floor tiles located in the kitchen on the floor by the 3-bay sink around the grease trap and water was noted pooling in this area that measured approximately 36 x 12.

Inspectors wroteBased on staff interviews and record review conducted during a Recertification Survey, the facility did not ensure that investigation results of all alleged violations involving misappropriation of property are reported within a timely manner to the New York State Department of Health (NYSDOH). This was evident in 3 out of 5 residents reviewed for personal property (Residents #73, #83 and #286). Specifically, the facility failed to report to the NYSDOH a pattern of misplacing/theft upon discovery and/or after investigating 1) Resident #73's missing necklace, 2) Resident #83's missing rings and 3) Resident #286's missing Grand-Pad within 24 hours.

Inspectors wroteBased on record reviews and interviews during a Recertification Survey, the facility did not ensure that resident Comprehensive Care Plans (CCP) were reviewed and revised to meet resident needs consistent with their rights. This was evident in 2 of 5 residents reviewed for personal property (Resident #73 and Resident #83). Specifically, Residents #73 and #83 had no documented evidence of person-centered goals or appropriate interventions specific to missing personal property in the facility. Resident #73 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses including COVID-19, Cerebrovascular disease, and Dementia. The Minimum Data Set (MDS; a resident assessment tool) dated 3/1/2021 documented a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severely impaired cognition. [...]

Inspectors wroteBased on record review and interview during a Recertification Survey, the facility did not ensure that catheter care was provided in accordance with professional standards of care. This was evident for 1 of 1 residents (Resident #97) reviewed for urinary catheter. Specifically, Resident #97 had no order for foley catheter care after readmission on [DATE] which resulted in the treatment not being rendered for 3 days.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification Survey, the facility did not ensure that all medications were stored in accordance with manufacturer's specifications and standards of practice. Specifically, in 1 of 4 medication rooms reviewed for medication storage on [DATE] (2 South), a multiple dose vial of Lantus Insulin was observed to be dated as opened on [DATE].

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure that 3 of 3 residents reviewed for dignity were provided care in a manner that promoted each resident's dignity. Specifically, urinary drainage bags were not concealed to prevent direct observation by visitors, staff and other residents. (Residents #37, 82, and 125.)

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure that written notices were sent to families or their representatives regarding transfer/discharge to the hospital or the reasons for the transfer/discharge. This was evident for 3 of 3 residents reviewed for hospitalization (Residents #66, #82, #62).