Lutheran Center At Poughkeepsie Inc

In the surveyor’s words

From the most serious findings on record at Lutheran Center At Poughkeepsie Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 14, 2026

  Based 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. […]

• Actual harm, isolatedF686Dec 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF684Apr 14, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF600Jan 23, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF609Jan 23, 2025

  Based 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. […]