Lutheran Center At Poughkeepsie Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Poughkeepsie, New York.
- Location
- 965 Dutchess Turnpike, Poughkeepsie, New York 12603
- CMS Provider Number
- 335810
- Inspections on file
- 18
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 5
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.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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