Lutheran Home Of Southbury Inc

In the surveyor’s words

From the most serious findings on record at Lutheran Home Of Southbury Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 16, 2026

  . Based on observations, review of the clinical record, facility documentation and facility policy, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure staff responded appropriately to wander guard alarms and failed to ensure staff visually verified residents before re-setting alarms, resulting in the resident leaving the nursing unit without staff knowledge. Further, the facility failed to maintain a secured exit door in proper working order and failed to ensure staff searched for a resident timely when an exit door alarm sounded, resulting in Resident #1 exiting the facility without staff knowledge or supervision. The failures resulted in the finding of Immediate Jeopardy. […]

• No harm, potential for more than minimal, patternF585Jun 17, 2025

  Based on observations, interviews, record and policy review, the facility failed to post and provide information or means to file a grievance and follow up on grievances. The findings included: 1. Resident #31's diagnoses included diabetes, chronic obstructive pulmonary disease, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was mildly cognitively impaired, required set up for eating and oral hygiene and substantial/maximal assistance for dressing and transfers. 2. […]

• No harm, potential for more than minimal, patternF603Jun 17, 2025

  Based on observations and staff interviews for 30 residents reviewed for placement on a secured unit, the facility failed to identify required clinical criteria for placement on the unit, failed to develop a policy for the secured unit, and failed to document that information for independent egress had been provided to appropriate residents. The findings include: Observations on 6/9/25, 6/10/25, 6/11/25, 6/16/25, and 6/17/25 identified 30 residents resided on the lower level secured unit. Although entrance onto the unit did not require a code to enter, exit from any of the doors (including the door used to enter that unit) on the unit required input of a number code into a keypad adjacent to the door. […]

• No harm, potential for more than minimal, patternF880Aug 24, 2021

  Based on observations, facility documentation review, facility policy review and staff interviews for infection control review, the facility failed to ensure that staff followed Infection Control Guidelines and/or the Centers for Disease Control and Prevention (CDC) guidance related to COVID-19 isolation precautions and PPE use. The findings included: 1. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident care plan dated 8/14/2021 identified that Resident #1 had direct contact with a staff member who was positive for COVID-19. Interventions directed contact and droplet precautions, and to encourage Resident #1 to wear a mask. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF761Jul 20, 2021

  Based on observation, review of facility documentation, facility policy and interview for 2 of 3 medication storage rooms, the facility failed to maintain the rooms in a secure manner and according to policy. The findings include: Observation on 7/18/21 at 5:15 AM identified the C-2 North unit and C-2 South unit's medication rooms were open/unsecured. The C-2 North's medication room door was propped completely open with a wedge. NA #1 was noted near the Nurse's station at that time and LPN #1 was noted halfway down the C-2 North's hallway. RN #2 was noted off C-2 South unit in adjacent hallway. Subsequent observation of C-2 South's medication room with RN #1 identified the medication room was unlocked and slightly open. […]