Inspection Reports for Lutheran Home Of Southbury Inc

A desk audit was completed to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, focusing on previous deficiencies cited on 2025-06-17.

The facility corrected all previously cited deficiencies (1-10) and was found to be in compliance with all regulations as of 2025-07-29. No new non-compliance was identified.

A complaint investigation survey was conducted to determine compliance with 42 CFR Part 483 requirements for long term care facilities.

Deficiencies and/or violations were cited as a result of this survey.

Complaint Investigation Survey, ACT Reference Numbers CT # 35377 and #42744.

The visit was a desk audit conducted as part of the licensing inspection process on December 3, 2024.

No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. The administrator was notified via telephone that all violations were corrected.

The inspection visit was conducted as a complaint investigation related to Complaint #37610.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint investigation #37610 was conducted and found no violations; the complaint was not substantiated.

A desk audit was conducted on 11/9/21 to review the plan of correction for a violation letter dated 8/24/21 related to ADL Care Provided for Dependent Residents.

No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this desk audit inspection. The previously identified violation has been corrected.

An unannounced visit was conducted at Lutheran Home Of Southbury Inc on August 24, 2021, by the Department of Public Health for the purpose of conducting a COVID-19 Focused Infection Control Survey.

The survey identified deficiencies related to infection control practices including improper use of personal protective equipment (PPE), lack of facility policies for handling linens and reusable gowns for COVID-19 residents, and inadequate signage for COVID-19 exposed and quarantined units. Education and corrective actions were planned to address these issues.

An unannounced visit was made to Lutheran Home Of Southbury, Inc. on July 20, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a licensure and recertification inspection.

The report details multiple violations of the Regulations of Connecticut State Agencies identified during the inspection, including failures in notifying physicians of resident refusals, failure to provide treatment for edema, failure to implement fall prevention measures, medication room security issues, failure to wear hair restraints in the kitchen, inadequate infection control related to hand washing, and failure to obtain and document vaccination histories and administration. Plans of correction were submitted for each violation with specified compliance dates.

A Recertification survey was conducted on 7/18, 7/19 and 7/20/21 at Lutheran Home Southbury to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Deficiencies were cited related to failure to notify physician of resident treatment refusals, failure to provide treatment for lower extremity edema, failure to implement fall prevention measures, unsecured medication rooms, failure to wear hair restraints in the kitchen, improper hand hygiene practices, and failure to obtain and administer pneumococcal vaccinations.

The inspection visit was conducted as a complaint investigation, referenced by complaint investigation number 30344.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint investigation number 30344 was conducted and found no violations.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

No deficiencies were cited as a result of this COVID-19 focused survey.

The inspection was a licensure renewal inspection conducted over multiple days from March 9 to March 12, 2020, to assess compliance with Connecticut state regulations and licensing requirements.

Violations of Connecticut state statutes and regulations were identified during the inspection, including failure to discard expired intravenous solutions and failure to maintain the kitchen in a sanitary manner. Plans of correction were required to address these deficiencies.

Unannounced visits were made to Lutheran Home Of Southbury Inc which concluded on March 12, 2020 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation, a licensure and a certification inspection.

The facility failed to discard expired Intravenous (IV) Solutions found in the Emergency Medication Storage System and failed to maintain the kitchen in a sanitary manner with multiple issues including standing water, debris accumulation, and unclean equipment. Plans of correction were submitted with completion dates of November 10, 2020.

A follow up/desk audit was conducted for Lutheran Home of Southbury on 6/14/19 for the purpose of reviewing the implementation of the plan of correction for a violation letter dated 4/16/19.

A review of staff education, policy/procedures and audits submitted by the facility was conducted. All violations, 1a, 2a, 3a, and 4a were noted as corrected. No violations were identified at the time of this inspection.

A follow up/desk audit was conducted for Lutheran Home of Southbury on 6/14/19 to review the implementation of the plan of correction for a violation letter dated 4/16/19.

A review of staff education, policy/procedures, and audits submitted by the facility was conducted. All violations (1a, 2a, 3a, and 4a) were noted as corrected and no violations were identified at the time of this inspection.

Unannounced visits were made to the facility on February 19, 20, 21, and 25, 2019 for the purpose of conducting multiple investigations and a certification survey.

The facility was found deficient in several areas including failure to ensure timely RN assessments for skin condition changes, failure to implement splinting devices as ordered, medication administration errors related to anticonvulsant dosing, and failure to ensure food service safety standards such as beard restraints for dietary staff.

The inspection was conducted as a complaint investigation triggered by multiple complaint numbers (#23606, 24139, 24204, 24916) with unannounced visits on February 19, 20, 21, and 25, 2019 to assess compliance with Connecticut state regulations.

Violations of Connecticut General Statutes and regulations were identified related to nursing assessments, medication administration, positioning/mobility, and dietary services. The facility failed to ensure timely RN assessments for skin condition changes, proper medication administration, implementation of splinting devices, and food service safety standards.

Complaint investigation involved multiple complaints (#23606, 24139, 24204, 24916). Violations were substantiated as indicated by citations and violation letters issued.

Unannounced visits were made to Lutheran Home Of Southbury Inc on February 29, 20, 21 and 25, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations and a certification inspection.

The report details multiple violations of Connecticut state regulations related to nursing assessments, medication administration, splinting device implementation, and food service safety. The facility failed to ensure timely RN assessments for skin condition changes, proper medication administration, and adherence to physician orders for splinting devices. Dietary staff failed to comply with beard restraint policies. Plans of correction were submitted for each violation.

Complaints #23606, 24139, 24204, 24916 were investigated as part of the visit.