Lutheran Center At Poughkeepsie Inc

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 REDACTED] documented Resident #1 as dependent for bed mobility on their functional assessment. The findings are: The facility did not have a policy related to the Minimum Data Set assessment.Resident #1 was admitted with diagnoses including but not limited to Dementia, Unspecified Intracapsular fracture of right femur and Type 2 Diabetes Mellitus. An Admission/Medicare 5 Day Minimum Data Set, dated [DATE REDACTED] documented Resident #1 had severe cognitive impairment. The resident had impairment to the lower extremity on one side and required a walker or a wheelchair for locomotion. The resident required set up assistance with meals and was dependent for toileting, bed mobility and transfers. The resident was not on

a turning and positioning program. Review of the activities of daily living care plan dated 08/20/2025 documented Resident #1 had a self-care performance deficit related to activity intolerance, confusion and disease processes. Interventions listed included to encourage the resident to fully participate possible with each interaction and praise all efforts of self-care. Review of a rehabilitation progress note dated 08/22/2025 at 12:32 PM documented Resident #1 was evaluated for Physical Therapy and was found to have the following mobility levels: maximum assistance for bed mobility, sit to stand pivot transfers are a maximum assistant of two people, toilet transfers with extensive assistance of two people. Resident #1 was currently not ambulatory and was dependent for wheelchair mobility. During an interview on 10/09/2025 at 11:37 AM, Licensed Practical Nurse #1 stated Resident #1 was mobility dependent. During an interview on 10/9/2025 at 12:56 PM, Registered Nurse #2 stated in the functional assessment section of the minimum data set, the rehabilitation department completes this section, and it is then signed off by nursing.

Registered Nurse #2 stated an entry for Resident #1 was coded as dependent for bed mobility and they would think the resident would have turning and positioning orders or have their heels elevated. Attempts to reach Physical Therapist #1 on 10/23/2025 was unsuccessful. 10 NYCRR 415.11(b)

Residents Affected - Few Note: The nursing home is disputing this citation.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lutheran Center at Poughkeepsie Inc

965 Dutchess Turnpike Poughkeepsie, NY 12603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Practitioner #2 stated they had not worked in the facility since 12/08/2025. When they worked at the facility,

they made wound rounds weekly with the staff nurses and unit managers for each unit and evaluated all residents with wounds in the facility. Nurse Practitioner #2 stated at the bottom of their progress notes, there is a section where they document the need for turning and positioning, offloading the heels and the need for air mattress. Nurse Practitioner #2 stated these measures are discussed with the unit manager as

they are responsible for implementing the orders. Nurse Practitioner #2 stated the unit manager would be

the one to pick up the orders for offloading and turning and positioning after informing the Attending Physician of the recommendations from the wound consult. Nurse Practitioner #2 stated they would check

the residents orders the same day to ensure they were picked up by staff and the nurses usually pick up the orders before they even leave the unit. Nurse Practitioner #2 stated they were informed there was a protocol for turning/repositioning, but they are not sure how often. They assumed it had to be turning every two (2) hours. Nurse Practitioner #2 stated if they determine a change is needed to the orders for the wound they communicate the changes to the staff, so it is documented. Nurse Practitioner #2 stated they also document their wound round notes in the progress notes. Nurse Practitioner #2 stated they do not recall Resident #1 specifically, but they remember when they would evaluate wounds in the facility, they were staged differently by the previous wound doctor than what they observed. Nurse Practitioner #2 stated

they stand by their assessment documented in Resident's medical record. When they saw Resident #1 with

the wound nurse, they observed Resident #1's wound was unstageable and that is what they documented. 10 NYCRR 415.12(c)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lutheran Center at Poughkeepsie Inc

965 Dutchess Turnpike Poughkeepsie, NY 12603

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based 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.The findings are: During an interview

on 10/9/2025 at 1:00 PM, the Director of Nursing stated they do not have a policy related to Braden scale assessments and it is a Corporate issue. The Director of Nursing stated they are doing their best and will try to address all these issues brought up during the onsite survey. The Director of Nursing stated the facility does not have a skin observation policy or an admission assessment policy. They were not sure if

the facility has a minimum data set policy and they know this is a problem, but it is a corporate issue. The Director of Nursing stated they are trying to make changes and update the facility policies. The Director of Nursing stated they asked the Administrator about the policies requested and was informed that they did not need a policy for everything in the facility. 10 NYCRR 415.26

Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet