Inspection Reports for
Lutheran Center at Poughkeepsie, Inc
965 Duthcess Turnpike, Poughkeepsie, NY, 12603
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Dec 26, 2025
Visit Reason
The inspection was an abbreviated survey to assess compliance with regulatory requirements related to resident assessments, pressure ulcer care, and facility resource management.
Findings
The facility failed to ensure accurate resident assessments, appropriate pressure ulcer prevention and care, and effective use of resources. Deficiencies included inaccurate Minimum Data Set assessments, inadequate pressure ulcer prevention leading to actual harm, and lack of documented facility policies for key assessments and care procedures.
Deficiencies (3)
F 0641: The facility did not ensure assessments accurately reflected Resident #1's status, with discrepancies in bed mobility documentation and lack of a Minimum Data Set assessment policy.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident #1, resulting in actual harm from unstageable pressure ulcers and deep tissue injury due to inconsistent offloading and turning.
F 0835: The facility administrator did not ensure effective and efficient use of resources, failing to provide requested facility policies for Braden scale assessments, skin observation, admission assessments, and Minimum Data Set assessments.
Report Facts
Residents affected: 1
Skin observation missed signings: 44
Wound measurements: 3.1
Wound measurements: 1.4
Wound measurements: 1.2
Wound measurements: 2.4
Braden score: 14
Skin observation missed signings: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #2 | Nurse Practitioner | Provided wound care assessments and documented wound status and care orders |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Provided interviews regarding Resident #1's mobility and pressure injury status |
| Registered Nurse #2 | Registered Nurse | Interviewed about functional assessment and Minimum Data Set completion |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies and resource management |
| Registered Nurse #3 | Registered Nurse | Documented nursing progress notes related to Resident #1's pressure injury |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Jan 23, 2025
Visit Reason
The visit was an abbreviated survey to assess compliance with resident rights, abuse prevention, timely reporting, and care planning at Lutheran Center at Poughkeepsie Inc.
Findings
The facility was found deficient in ensuring residents' rights to dignity during meals, protecting residents from abuse, timely reporting of abuse investigations, and developing comprehensive person-centered care plans for residents at risk of victimization.
Deficiencies (4)
F 0550: The facility failed to ensure residents' right to a dignified existence when a Certified Nurse Assistant was observed standing over a resident while assisting with a meal instead of sitting.
F 0600: The facility failed to protect residents from abuse when staff engaged in verbal and physical altercations with residents, including taunting and physical tussling, and verbal aggression by therapy staff causing psychological distress.
F 0609: The facility failed to timely report the results of abuse investigations to the New York State Department of Health within the required timeframe for multiple incidents involving residents and staff.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans addressing risk of victimization for residents involved in abuse incidents, including lack of abuse or victim care plans for residents with cognitive impairment or behavioral issues.
Report Facts
Residents Affected: 1
Residents Affected: 2
Residents Affected: 3
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Involved in verbal and physical altercation with Resident #1 and cited in abuse findings |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Observed standing while assisting Resident #4 with meal, cited in dignity deficiency |
| Physical Therapy Assistant #2 | Physical Therapy Assistant | Verbally aggressive with Resident #3 causing psychological distress |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding staff meal assistance practices |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding deficiencies, staff training, and care plan oversight |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about care plan updates and resident interactions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Jan 23, 2025
Visit Reason
Complaint Survey with 4 standard health citations related to quality of care and resident rights, all corrected by February 18, 2025.
Findings
Complaint Survey with 4 standard health citations related to quality of care and resident rights, all corrected by February 18, 2025.
Deficiencies (4)
Develop/implement comprehensive care plan
Free from abuse and neglect
Reporting of alleged violations
Resident rights/exercise of rights
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
Covid-19 Survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 6, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards for nursing home care, food safety, infection control, equipment maintenance, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to ensure residents received correct meal textures and adequate supervision to prevent accidents, unsanitary kitchen conditions, improper infection control practices, failure to offer pneumococcal vaccinations to residents, and unsafe maintenance of essential equipment such as pooling water and missing floor tiles in the kitchen.
Deficiencies (5)
F 0689: The facility failed to ensure Resident #24 received the correct mechanical soft, ground meat diet as ordered, and Resident #62's care plan was not implemented, resulting in a fall with major injury.
F 0812: The kitchen was not maintained in sanitary condition, with dirty and dusty fans blowing on clean dishes, ovens and stove with caked-on grease, dusty ceiling tiles and vents, and a foul odor present.
F 0880: Staff did not maintain an infection prevention and control program; clean linen was handled with dirty gloves and clean PPE carts were improperly stored inside isolation rooms.
F 0883: The facility failed to ensure Resident #49 was offered pneumococcal immunization or provided education regarding the vaccine.
F 0908: Essential equipment was not maintained safely; missing floor tiles and pooling water were observed in the kitchen around the grease trap and 3-bay sink area.
Report Facts
Measurement of pooling water: 36
Measurement of pooling water: 12
Residents reviewed for pneumococcal immunization: 5
Residents reviewed for infection prevention: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #8 | Licensed Practical Nurse | Named in finding related to incorrect meal texture served to Resident #24 |
| Staff #13 | Cook | Named in finding related to meal preparation error for Resident #24 |
| Staff #15 | Speech Therapist | Named in finding related to diet appropriateness for Resident #24 |
| Staff #1 | Certified Nursing Assistant | Named in finding related to fall of Resident #62 |
| Staff #22 | Certified Nurses Assistant | Named in infection control finding for handling clean linen with dirty gloves |
| Staff #28 | Infection Preventionist | Named in infection control and pneumococcal vaccine findings |
| Staff #32 | Registered Nurse Unit Manager | Named in infection control finding regarding PPE cart placement |
| Staff #33 | Food Service Director | Named in kitchen sanitation and equipment maintenance findings |
| Staff #34 | Director of Planning | Named in kitchen equipment maintenance finding |
| Staff #35 | Cook | Named in kitchen equipment maintenance finding |
| Nurse Practitioner #6 | Named in finding related to Resident #24 diet order review | |
| Staff #3 | Licensed Practical Nurse Manager | Named in interview regarding Resident #62 fall |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Feb 6, 2024
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, timely reporting of abuse, accident prevention, medication storage, food safety and sanitation, infection control, vaccination policies, and maintenance of essential equipment.
Deficiencies (8)
F 0550: The facility failed to ensure residents were treated with respect and dignity; Resident #49 wore a food-stained gown during meals and feeding instructions for Resident #116 were posted visibly above the bed.
F 0609: The facility did not timely report three resident-to-resident altercations involving Resident #126 to the State Survey Agency as required.
F 0689: The facility failed to provide adequate supervision and assistance devices to prevent accidents for Residents #24 and #62; Resident #24 received incorrect meal texture and Resident #62 sustained a fall with major injury due to incomplete care plan implementation.
F 0761: The facility did not ensure drugs and biologicals were stored in locked compartments; 8 blister packs of medications were found unsecured in an unlocked office accessible to wandering residents.
F 0812: The facility failed to maintain food contact and non-food contact equipment and kitchenware in sanitary condition; dirty fan blowing on clean dishes, greasy ovens and stove, dusty ceiling tiles and vents, and foul kitchen odor were observed.
F 0880: The facility did not maintain an effective infection prevention and control program; staff were observed handling clean linen with dirty gloves and clean PPE carts were stored inside isolation rooms.
F 0883: The facility failed to ensure residents were offered pneumococcal vaccinations and educated on benefits and side effects; Resident #49 had no documented evidence of being offered or declining the vaccine.
F 0908: The facility did not maintain essential equipment safely; missing floor tiles and pooling water around the kitchen grease trap and 3-bay sink created unsafe conditions.
Report Facts
Resident-to-resident altercations not reported: 3
Blister packs of unsecured medications: 8
Pooling water area: 36
Pooling water area: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Certified Nursing Assistant | Named in findings related to Resident #49 dignity and Resident #62 fall |
| Staff #2 | Certified Nursing Assistant | Named in findings related to Resident #49 dignity |
| Staff #8 | Licensed Practical Nurse | Named in findings related to Resident #24 meal supervision |
| Staff #13 | Cook | Named in findings related to kitchen sanitation and meal preparation |
| Staff #15 | Speech Pathologist | Named in findings related to feeding instructions for Resident #116 and diet supervision |
| Staff #22 | Certified Nurses Assistant | Named in infection control deficiency for handling clean linen with dirty gloves |
| Staff #27 | Registered Nurse Unit Manager | Named in medication storage and feeding instruction signage findings |
| Staff #28 | Infection Preventionist | Named in infection control and vaccination policy findings |
| Staff #33 | Food Service Director | Named in kitchen sanitation and equipment maintenance findings |
| Staff #34 | Director of Planning | Named in kitchen sanitation and equipment maintenance findings |
| Staff #35 | Cook | Named in kitchen equipment maintenance findings |
| Director of Nursing | Interviewed regarding abuse reporting and vaccination policy | |
| Nurse Practitioner #6 | Nurse Practitioner | Named in findings related to Resident #24 diet order |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 19
Date: Feb 6, 2024
Visit Reason
Complaint Survey with 10 standard health citations and 9 life safety code citations, all Level 2 severity, all corrected by April 2024.
Findings
Complaint Survey with 10 standard health citations and 9 life safety code citations, all Level 2 severity, all corrected by April 2024.
Deficiencies (19)
Criminal history record check process
Department criminal history review
Essential equipment, safe operating condition
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection prevention & control
Influenza and pneumococcal immunizations
Label/store drugs and biologicals
Reporting of alleged violations
Resident rights/exercise of rights
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Emergency lighting
Fire alarm system - testing and maintenance
Fundamentals - building system categories
Hazardous areas - enclosure
Hvac
Sprinkler system - installation
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 16, 2021
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in timely reporting of suspected abuse or theft, failure to develop appropriate care plans for residents with missing personal property, inadequate catheter care due to missing orders and documentation, and improper medication storage with expired insulin vial found.
Deficiencies (4)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft involving misappropriation of resident property to the New York State Department of Health for 3 residents with missing personal belongings.
F 0656: The facility did not ensure resident Comprehensive Care Plans were reviewed and revised to meet resident needs, lacking person-centered goals and interventions for residents with missing personal property.
F 0690: The facility failed to provide appropriate catheter care for a resident due to absence of a foley catheter care order for 3 days after readmission.
F 0761: The facility did not ensure all medications were stored according to standards; an opened vial of Lantus Insulin was found dated beyond the 28-day discard period.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Medication rooms reviewed: 4
Medication rooms with deficiency: 1
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 7, 2020
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility failed to ensure that residents' dignity was maintained by not concealing urinary drainage bags for 3 residents. Additionally, the facility did not provide timely written notification to families or representatives regarding resident transfers or discharges to the hospital for 3 residents.
Deficiencies (2)
F 0550: The facility did not ensure that urinary drainage bags were concealed to protect residents' dignity for 3 residents. Bags were observed uncovered and visible to visitors and staff.
F 0623: The facility failed to provide written notification to families or representatives regarding resident transfers or discharges to the hospital for 3 residents. Only telephone notifications were documented.
Report Facts
Residents reviewed for dignity: 3
Residents reviewed for hospitalization notification: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) Unit Manager | Interviewed regarding urinary drainage bag coverage | |
| Infection Control Nurse / Assistant Director of Nursing (ADON) | Interviewed regarding education on urinary drainage bag coverage | |
| Director of Social Work (DSW) | Interviewed regarding written notification of resident transfers/discharges |
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