Cycle 1
Health 2024-02-06 · Fire 2024-02-06
11 health deficiencies
Top issue: Infection Control (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Poughkeepsie, NY
Lutheran Center At Poughkeepsie Inc
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
965 Dutchess Turnpike, Poughkeepsie, NY
(845) 486-9494
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
151
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-09-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.32
Baseline 20.98% · Performance 19.89% · Measure score 3.32 · Achievement 3.32 · Improvement 2.24
Healthcare-associated infections
2.48
Baseline 7.86% · Performance 7.09% · Measure score 2.48 · Achievement 2.48 · Improvement 2.17
Total nurse turnover
4.01
Baseline 37.31% · Performance 47.30% · Measure score 4.01 · Achievement 4.01 · Improvement 0
Adjusted total nurse staffing
2.61
Baseline 3.32 hours · Performance 3.82 hours · Measure score 2.61 · Achievement 2.61 · Improvement 1.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.27% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 536 · Observed rate 10.45% · Lower 95% interval 8.82% |
| Discharge to community | 61.97% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 557 · Observed rate 57.63% · Lower 95% interval 57.84% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.49% |
95.27%
4.2 pts better
|
Numerator 389 · Denominator 391 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 391 |
| Discharge self-care score | 62.62% |
53.69%
8.9 pts better
|
Numerator 201 · Denominator 321 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 214 · Denominator 321 |
| Pressure ulcers or injuries, new or worsened | 0.77% |
2.29%
1.5 pts better
|
Numerator 3 · Denominator 391 · Adjusted rate 0.99% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 335 · Observed rate 5.97% · Lower 95% interval 5.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 248 |
| Staff flu vaccination coverage | 42.31% |
42%
0.3 pts better
|
Numerator 99 · Denominator 234 |
| Discharge function score | 59.81% |
56.45%
3.4 pts better
|
Numerator 192 · Denominator 321 |
| Transfer of health information to provider | 92.68% |
95.95%
3.3 pts worse
|
Numerator 152 · Denominator 164 |
| Transfer of health information to patient | 97.96% |
96.28%
1.7 pts better
|
Numerator 192 · Denominator 196 |
| Resident COVID-19 vaccinations up to date | 55.94% |
25.2%
30.7 pts better
|
Numerator 113 · Denominator 202 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.2%
7.9 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 99.1% · Q3 100.0% · Q4 99.1% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.7% · Q3 2.7% · Q4 2.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.1%
2.8 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.0% · Q3 4.2% · Q4 6.2% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
13.5%
0.4 pts worse
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 12.5% · Q3 13.7% · Q4 16.2% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
14.8%
6.6 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.7% · Q3 6.9% · Q4 7.9% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.6% |
15.1%
8.5 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 21.9% · Q3 23.7% · Q4 23.2% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
15.5%
1.5 pts better
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 15.1% · Q3 16.1% · Q4 11.2% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.4%
0.7 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 1.9% · Q4 2.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
20.8%
4.4 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 28.9% · Q3 25.1% · Q4 24.5% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
6.9%
3.5 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.0% · Q3 4.6% · Q4 5.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
76.7%
20.8 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 97.8% · Q3 98.3% · Q4 95.6% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
9.7%
4.2 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 5.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
78.8%
19.7 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
20.6%
5.1 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 23.4% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-16 · Fire 2021-04-16
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2020-02-07 · Fire 2020-02-07
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-06
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-01
E · Potential for more than minimal harm
2021-04-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-06-17
E · Potential for more than minimal harm
2021-04-16
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-06-17
E · Potential for more than minimal harm
2021-04-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-17
E · Potential for more than minimal harm
2021-04-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-17
E · Potential for more than minimal harm
2021-04-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-17
D · Potential for more than minimal harm
2021-04-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-06-17
E · Potential for more than minimal harm
2020-02-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-04-23
E · Potential for more than minimal harm
2020-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-02-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-02-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-02-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-04-23
Inspection history
Recent health citations
G · Actual harm
2025-12-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2025-12-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Not marked corrected
D · Potential for more than minimal harm
2025-12-26
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Not marked corrected
E · Potential for more than minimal harm
2025-01-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-18
E · Potential for more than minimal harm
2025-01-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-02-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-10
D · Potential for more than minimal harm
2021-04-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-04-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-06-16
D · Potential for more than minimal harm
2020-02-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-03-03
B · Minimal harm
2020-02-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-03-03
Penalties and ownership
What sits behind the stars
Ownership
Eisgruber, Johna
Corporate Director · Individual
Eisgruber, Johna
W-2 Managing Employee · Individual
Fellegara, Laraine
Corporate Officer · Individual
Fellegara, Laraine
W-2 Managing Employee · Individual
Ludington, Patricia
Corporate Director · Individual
Ludington, Patricia
W-2 Managing Employee · Individual
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4-star overall rating with 3-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
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2-star overall rating with 3-star inspections with 4 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
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