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 Lutheran Center At Poughkeepsie Inc during CMS and state inspections, most recent first.
Two residents did not receive adequate supervision to prevent accidents. One resident with dementia, severe cognitive impairment, gait problems, and a known elopement risk exited through an alarmed fire door while staff on the unit did not promptly respond to the sounding alarm; the resident was later found outside on the ground with facial and extremity abrasions. Another high fall-risk resident with renal failure, on dialysis, and with a history of multiple recent falls was seated in the dining room, care planned to remain in view of staff, while a CNA who had agreed to supervise sat at a distance looking at their phone and out the window; the resident repeatedly leaned forward and ultimately fell from the wheelchair, sustaining a large bump to the forehead.
Surveyors found that the facility did not ensure residents received care according to professional standards, physician orders, care plans, and resident choices. One resident with urinary symptoms had an order for a urine dipstick and conditional urinalysis/culture, but there was no documentation that the dipstick was done, the initial urine specimen was not processed, and the culture was only obtained after antibiotics had already been started. Another resident needing replacement AFOs experienced a delay in orthotic fitting because, although the prescription and note were completed, rehabilitation staff did not forward the required paperwork to the orthotics company, causing a scheduled appointment to be postponed. A third resident on an anticoagulation care plan requested discontinuation of Eliquis and was switched to aspirin, but staff did not document the refusals, did not record any education on the effects of stopping the medication, and did not update the care plan to reflect the change.
A resident with significant risk factors for skin breakdown did not receive consistent pressure ulcer prevention interventions, including turning, repositioning, and heel offloading. Inadequate monitoring and documentation by staff led to the development of a Stage 2 pressure injury that progressed to an unstageable wound, as well as a deep tissue injury to the heel. Staff interviews confirmed lapses in following wound prevention protocols, resulting in actual harm.
A resident with severe cognitive impairment and mobility limitations was assessed by Physical Therapy as requiring maximum assistance for bed mobility, but the admission MDS documented the resident as dependent, creating a discrepancy. The facility did not have a policy for MDS assessments, and staff interviews highlighted inconsistencies in the assessment and care planning process.
Surveyors found that the facility did not have documented policies for Braden scale assessments, skin observation, admission assessments, or MDS assessments. The DON stated these were corporate issues and acknowledged the absence of such policies, while the administrator indicated that not every process required a policy.
Two residents experienced abuse in an LTC facility. One resident with cognitive impairment was taunted and physically engaged by a CNA, leading to a tussle. Another resident, cognitively intact, faced verbal aggression from a PTA regarding their discharge plan, causing psychological distress. The facility failed to prevent these incidents, lacking an abuse care plan and delaying investigation responses.
The facility failed to report investigation results of abuse and mistreatment within the required timeframe for three residents. Incidents included a CNA's altercation with a resident, inappropriate contact by another CNA, and a distressing interaction with a Physical Therapy Assistant. The Director of Nursing was unaware of the five-day reporting requirement, causing delays.
A resident with severe cognitive impairment was assisted with their meal by a CNA who stood over them, contrary to the facility's policy that staff should be seated. The resident's care plan emphasized dignified meal consumption, and the CNA acknowledged awareness of the requirement. Interviews confirmed that staff are trained to be seated during meal assistance.
The facility failed to develop and implement comprehensive care plans for two residents, leading to incidents that compromised their well-being. One resident, with severe cognitive impairment, was involved in a physical altercation with a CNA, while another resident experienced mental distress after a verbal altercation with a Physical Therapy Assistant. The facility lacked a policy for updating care plans, resulting in deficiencies in resident care.
Failure to Respond to Door Alarm and Inadequate Supervision of High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for two residents identified as being at risk for elopement and falls. One resident with encephalopathy, dementia, gait difficulties, severely impaired cognition, and a documented history of wandering and elopement risk was care planned with an electronic monitoring device, hourly monitoring of location, and interventions for wandering and exit-seeking. Despite these measures, on the evening of 03/25/2026, this resident was last seen at dinner asking about their truck and car, then left the unit through an alarmed fire exit door. Camera footage showed the resident walking down the hallway, passing the fire door, turning back, and exiting through the fire door. The fire door alarm sounded, but staff did not respond to the alarm for several minutes. During the period after the alarm sounded, multiple staff were present on the unit but did not immediately investigate the source of the alarm. Statements from CNAs and LPNs indicated that some staff were in resident rooms with loud radios or televisions and did not hear the alarm, while another LPN was at the nurses’ station giving medications. One CNA reported being unfamiliar with the sound of the fire door alarm and, seeing an LPN at the nurses’ station not reacting, continued with resident care instead of checking the alarm. The alarm panel later showed the alert was from the hallway where the fire door was located. When an LPN returning from a CPR class finally checked the alarm panel and went to the fire door, the resident was found lying on the ground in the parking lot approximately 114 feet from the door, with a laceration to the forehead and abrasions to the nose, cheeks, shoulder, and knees, and was subsequently evaluated in the emergency department. The second resident involved in the deficiency had renal failure, was on dialysis, had rib fractures related to a prior fall, and was assessed as high risk for falls with multiple recent falls documented. The resident’s care plan identified them as high risk for falls and included interventions such as remaining in the dining room in view of staff, use of Dycem in the wheelchair, encouragement to use the call bell, and a low bed. On the morning of 04/07/2026, this resident was seated in a wheelchair in the dining room with visible bruising under both eyes and on the forehead from a prior fall. Video footage showed that a CNA, who had agreed to supervise the resident and was aware of the high fall risk, sat at a table by a window looking at their phone and out the window while the resident sat in a wheelchair in the center of the room, out of arm’s reach. The footage further showed the resident intermittently leaning forward in the wheelchair while the CNA remained seated away from the resident and did not reposition them closer or provide active supervision. At approximately 6:51 AM, the resident leaned forward and fell out of the wheelchair onto the floor in the dining room. The fall was unwitnessed in the sense that no staff were immediately at the resident’s side; the resident was later found on the floor in front of the wheelchair, lying on their right side, with a large raised bump on the right forehead. Nursing notes documented that the resident stated they tried to walk and fell. The DON later confirmed that the CNA should have been supervising the resident more closely and not looking at their phone and out the window while responsible for monitoring this high fall-risk resident.
Failure to Follow Orders, Coordinate Orthotic Services, and Document Anticoagulation Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, physician orders, person-centered care plans, and resident choices for three residents. One resident with cirrhosis, right hip fracture, and a colostomy had an elevated white blood cell count and reported burning and frequency with urination. The physician ordered a urine dipstick, with urinalysis and culture to be obtained if the dipstick was positive, and prescribed Zosyn every six hours for five days. There was no documented evidence that the urine dipstick was performed, and although staff reported collecting a urine specimen on the same day, there was no documentation of that collection and the sample was not processed because it was not picked up by the lab in time. A subsequent urine sample was not collected until several days later, after the antibiotic had already been started, and the culture showed an insignificant bacterial count. Another resident with spinal stenosis, paraplegia, and scoliosis required bilateral Ankle Foot Orthoses (AFOs) and had poor tolerance of the existing orthotics, which could not be repaired or modified. The physician documented that replacement AFOs were necessary and an order for bilateral AFOs was obtained. The orthotics company notified the facility that an upcoming orthotics appointment would need the prescription and physician note beforehand, and later informed the facility that the appointment had to be postponed because the required paperwork had not been received. The Director of Rehabilitation and the Director of Rehabilitation for Long Term Care acknowledged that the physician note and order had been completed but were not forwarded to the orthotics company, resulting in a delay in scheduling the casting appointment for the new orthotics. A third resident with atrial fibrillation, heart failure, and generalized weakness was on an anticoagulation care plan that included Eliquis, with interventions to monitor for signs of bleeding, bruising, and labs as ordered. A physician order prescribed Eliquis twice daily for atrial fibrillation, which was later discontinued and replaced with a daily aspirin order for anticoagulation after the resident requested discontinuation of Eliquis. The resident reported that they had requested the Eliquis be stopped, and an LPN stated the resident had been refusing the medication and that the physician was aware. However, there was no nursing or physician documentation of the resident’s refusal, no documented education or discussion about the medication and possible effects of discontinuation, and the care plan was not updated to reflect the discontinuation of Eliquis and the change to aspirin.
Failure to Prevent and Manage Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers and to ensure that a resident did not develop avoidable pressure ulcers. A resident with multiple risk factors, including dementia, a recent hip fracture, and diabetes, was admitted with a blanchable area of moisture-associated skin damage to the coccyx/buttocks and was dependent for bed mobility. Despite being identified as at moderate risk for pressure ulcers on the Braden Scale, there were no documented interventions such as turning and repositioning or heel offloading at admission, and the care plan did not include these risk reduction measures. The resident's care records showed inconsistent implementation and documentation of skin observations and heel offloading. Certified nurse aide accountability records indicated that skin checks were not signed as completed on multiple occasions, and heel offloading was not consistently performed as ordered. The resident subsequently developed a Stage 2 pressure injury on the left buttocks, which later progressed to an unstageable wound, and a deep tissue injury to the right heel. These injuries were attributed to the lack of consistent preventive interventions, such as turning, repositioning, and heel offloading, as well as inadequate monitoring and documentation by staff. Interviews with facility staff, including the DON, RNs, LPNs, and nurse practitioners, revealed gaps in communication and implementation of wound prevention protocols. Staff acknowledged that interventions like heel offloading and turning were not automatically initiated for high-risk residents and that orders and protocols were not always followed or documented. The facility's own wound management policy required comprehensive risk reduction measures, but these were not consistently applied, resulting in actual harm to the resident.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status for one out of three residents reviewed. Specifically, a resident admitted with diagnoses including dementia, an intracapsular fracture of the right femur, and type 2 diabetes mellitus was evaluated by Physical Therapy and found to require maximum assistance for bed mobility. However, the admission Minimum Data Set (MDS) documented the resident as dependent for bed mobility, which did not align with the Physical Therapy evaluation. The facility also lacked a policy related to the MDS assessment process. Further review of the resident's care plan indicated a self-care performance deficit due to activity intolerance, confusion, and disease processes, with interventions focused on encouraging participation in self-care. Interviews with nursing staff revealed that the rehabilitation department completed the functional assessment section of the MDS, which was then signed off by nursing. Staff noted that the resident was coded as dependent for bed mobility and questioned the absence of turning and positioning orders or heel elevation. Attempts to interview the Physical Therapist involved were unsuccessful.
Lack of Required Clinical Assessment Policies
Penalty
Summary
The facility administrator failed to ensure the effective and efficient use of facility resources to attain or maintain the highest practicable well-being of each resident, as evidenced by the inability to provide requested facility policies during an abbreviated survey. Specifically, the DON stated there were no documented facility policies for Braden scale assessments, skin observation, admission assessments, or Minimum Data Set (MDS) assessments. The DON indicated that the absence of these policies was a corporate issue and acknowledged the lack of documentation. The administrator reportedly informed the DON that not every process in the facility required a policy. These findings were based on record review and interviews conducted during the survey.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving two residents. In the first case, a resident with severe cognitive impairment and physical limitations was involved in a physical and verbal altercation with a Certified Nurse Assistant (CNA). The CNA was observed on video surveillance taunting and engaging in a shoving match with the resident in the dining room. The situation escalated to a physical altercation at the nurse's station, where the resident grabbed the CNA by the shirt, leading to a tussle. The CNA's actions, including kicking the resident's doll, which the resident believed to be their baby daughter, further agitated the resident. The facility's investigation revealed that the CNA had been provoking the resident, disregarding instructions from a registered nurse supervisor to de-escalate the situation. In the second case, a resident who was cognitively intact and required assistance with ambulation and daily activities reported verbal aggression from a Physical Therapy Assistant (PTA). The resident expressed concerns about their discharge plan, which had not been clearly communicated during a care plan meeting. The PTA responded in a stern manner, suggesting options that upset the resident, and threatened to involve Adult Protective Services if the resident insisted on going home without 24-hour supervision. This interaction caused the resident significant psychological distress, leading to sleeplessness and the need for antianxiety medication. The incident was reported by the resident, nursing staff, and a family member, highlighting the resident's ongoing worry and distress over the weekend. Both incidents demonstrate a failure by the facility to adhere to its Abuse Prohibition Protocol, which mandates the prevention of abuse and thorough investigation of alleged abuse cases. The facility did not have an abuse care plan in place for the first resident prior to the incident, and the response to the second resident's grievance was delayed, with the PTA not being immediately suspended pending investigation. These deficiencies indicate lapses in the facility's ability to protect residents from abuse and ensure their well-being.
Delayed Reporting of Abuse and Mistreatment Investigations
Penalty
Summary
The facility failed to report the results of investigations into allegations of abuse, neglect, or mistreatment to the New York State Department of Health within the required five working days for three residents. The first incident involved a Certified Nurse Assistant (CNA) engaging in a verbal altercation and physical struggle over a table with a resident who had severe cognitive impairment and required a wheelchair. The CNA's actions provoked the resident, leading to aggression. The investigative findings were not submitted until over a month later. In the second case, a resident with moderate cognitive impairment and visual issues reported inappropriate contact by a CNA. The resident described the CNA pecking them on the cheek, which made them uncomfortable. The investigation concluded there was no evidence of abuse, but the report was submitted nearly three weeks after the incident. The third incident involved a resident who was cognitively intact and reported feeling upset after a Physical Therapy Assistant spoke to them in a stern manner about their care options. The interaction caused the resident mental distress, and they refused further therapy with the assistant. The investigation's findings were submitted 16 days after the incident. The Director of Nursing was unaware of the five-day submission requirement, leading to delays in reporting.
Resident Dignity Compromised During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident's right to a dignified existence was upheld, as observed during an abbreviated survey. Specifically, a Certified Nurse Assistant (CNA) was seen standing over a resident while assisting them with their meal in the hallway, which is contrary to the facility's policy and training that staff should be seated when assisting residents with meals. This incident involved a resident with severe cognitive impairment and multiple diagnoses, including Schizoaffective Disorder and Intellectual Disabilities, who was dependent on staff for eating. The facility's Resident Rights policy emphasizes the importance of treating residents with dignity and respect, and the resident's care plan specified that meals should be consumed in a dignified manner. Despite this, the CNA acknowledged awareness of the requirement to be seated while assisting with meals but did not adhere to it. Interviews with the LPN and the Director of Nursing confirmed that staff are trained to be seated during meal assistance, and the CNA admitted to knowing this requirement.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans were developed and implemented for two residents, leading to incidents that compromised their well-being. Resident #1, who had severe cognitive impairment and required assistance for daily activities, was involved in a physical altercation with a Certified Nurse Assistant (CNA). Surveillance footage showed the CNA taunting Resident #1, which escalated into a physical tussle. Despite the resident's known cognitive impairments and behaviors, there was no abuse or potential victim care plan in place prior to the incident. Resident #3, who was cognitively intact and required assistance for mobility and daily activities, experienced a verbal altercation with a Physical Therapy Assistant. The interaction caused significant mental distress to the resident, who was not provided with a risk to be victimized care plan before or after the incident. The resident reported feeling upset and unable to sleep due to the interaction, which was not addressed in their care plan. The facility's policy required baseline care plans to be completed within 48 hours of admission, but there was no policy for updating and reviewing care plans. The Director of Nursing acknowledged the lack of a comprehensive care plan policy and stated that the responsibility for care plans was divided among unit managers and social workers. However, there was a failure to ensure that care plans were initiated and updated appropriately, leading to the deficiencies observed in the care of Residents #1 and #3.
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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.
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Nursing homes near Poughkeepsie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines At Poughkeepsie Ctr For Nursing & Rehab | 3.5 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nrsg At River Valley | 3.6 mi | ★★★★★ | 12 | 0 |
| Hudson Valley Rehabilitation & Extended Care Ctr | 5.9 mi | ★★★★★ | 37 | 0 |
| The Eleanor Nursing Care Center | 6 mi | ★★★★★ | 13 | 0 |
| Taconic Rehabilitation And Nursing At Ulster | 7.3 mi | ★★★★★ | 0 | 0 |
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