Inspection Reports for
Lutheran Home Of Southbury Inc

The complaint investigation involved allegations of misappropriation of resident property where Resident #1's cash money was removed from the facility safe. The investigation found the money missing and the Customer Service Liaison resigned. Additionally, complaints included failure to ensure receiving provider acceptance and failure to provide discharge summary for Resident #4, and failure to obtain a physician's order for Resident #4's discharge.

The facility failed to safeguard a resident's personal valuables resulting in missing cash, failed to ensure the receiving provider's acceptance and provide discharge summary prior to resident transfer, and failed to obtain a physician's order for discharge for a resident. These deficiencies were found to have minimal harm or potential for actual harm affecting a few residents.

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.

The facility was found deficient in multiple areas including failure to provide a dignified dining experience, failure to notify providers of positive orthostatic blood pressure, inadequate grievance posting and follow-up, lack of secured unit policy and criteria, failure to timely report injury of unknown origin, failure to offload heels for a high-risk resident, failure to prevent a fall due to inadequate supervision, failure to complete bi-monthly controlled medication audits, failure to document rationale for extended psychotropic medication use, and failure to provide adaptive feeding equipment as ordered.

The complaint investigation focused on Resident #1's agitation and restlessness without physician notification, and the inappropriate physical restraint involving a sheet tied around the resident's waist and wheelchair. The investigation found staff failed to notify the physician and improperly restrained the resident. Staff involved were suspended pending investigation.

The facility failed to ensure the physician was notified when Resident #1 exhibited restlessness and agitation. Additionally, the facility failed to ensure the resident was free from physical restraints, as a sheet was tied around Resident #1's waist and attached to the wheelchair, which was deemed an inappropriate restraint. Staff involved were suspended pending investigation.

The complaint involved an allegation of staff to resident abuse on 8/30/2024. The allegation was reported by NA #2 on 9/3/2024 after initially not reporting it. The allegation was unsubstantiated due to lack of witnesses other than NA #2 and denial by NA #1. The DON confirmed the allegation was unsubstantiated but noted failures in timely reporting and care provision.

The facility failed to ensure Resident #1 was treated with dignity and respect, failed to timely report an allegation of abuse, and failed to provide care in accordance with the plan of care. The abuse allegation was unsubstantiated due to lack of witnesses and conflicting statements. Staff education and audits were initiated following the incident.

The complaint investigation included review of clinical records, facility policies, interviews with staff and residents, and observations related to allegations of failure to notify representatives of changes in condition, medication errors, abuse reporting and investigation, care planning deficiencies, medication administration practices, respiratory care, and employee performance evaluations. Some allegations were substantiated with findings of minimal harm or potential for harm.

The facility was found deficient in multiple areas including failure to notify resident representatives of changes in condition, failure to notify physicians when medications were unavailable, failure to report and investigate abuse allegations timely and thoroughly, incomplete and outdated care plans especially related to nutrition, failure to verify resident identity before medication administration, failure to conduct RN assessments with changes in condition, failure to obtain daily weights as ordered, failure to administer medications per physician orders including delayed application of Lidocaine patches, failure to maintain and label oxygen equipment and post oxygen in use signs, and failure to conduct annual performance evaluations for nurse aides.

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.

The facility was found deficient in multiple areas including failure to notify the physician of treatment refusals, failure to provide ordered treatment for edema, inadequate fall prevention measures, unsecured medication storage rooms, failure to wear proper hair restraints in the kitchen, improper hand hygiene practices, and failure to obtain and administer pneumococcal vaccinations.

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.

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.

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.

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.

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.

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

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.

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

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.