Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Home Of Southbury Inc during CMS and state inspections, most recent first.
A resident with dementia and altered mental status had a care plan directing two-person assist for transfers, but therapy changed the transfer status to one assist and the update was not acted upon timely by nursing. The resident later fell during a transfer into a wheelchair, sustaining a head laceration, abrasions, and a headache, and was sent to the hospital. Interviews with the NA, DOR, and DON/DNS showed staff were using one-assist transfers, but the source of that change and whether the therapy recommendation was processed in the EMR queue could not be identified.
A resident with dementia and moderately impaired cognition was care planned for two-person transfer assistance, but a NA transferred the resident alone without a gait belt. The resident stood up quickly, turned during the transfer, caught a foot on the wheelchair, and fell, resulting in a head laceration, abrasions, headache, and hospital transfer.
Failure to safeguard a resident's cash and checkbooks occurred when money placed in the office safe went missing. The resident had dementia and poor decision-making skills, and nursing found cash hidden in the resident's clothing and bedding before locking it in a biohazard bag and then in the safe. Interviews showed the safe key was left unsecured in the office while the BOM and Asst. Biller left for a meeting, and the cash was later discovered missing from the safe.
A resident with anoxic brain damage, dementia, dysphagia, and other diagnoses was transferred after discharge plans changed from community return to another health care institution. Staff did not confirm the receiving provider’s acceptance before transfer and did not send the discharge summary before the resident arrived. Interviews showed the SW did not contact the receiving facility, and the administrator could not produce documentation showing the destination was confirmed or the summary was transmitted before the transfer.
Failure to Obtain Physician Order for Discharge: A resident with anoxic brain damage, dementia, dysphagia, and other diagnoses had a discharge plan focused on returning to the community, but nursing and APRN notes documented concerns that the spouse could not provide needed care and that the resident required 24-hour care. The resident was transferred to the hospital, yet the record did not show a physician's order for discharge, and the DNS confirmed the order was not obtained as required by facility policy.
A resident with dementia and behavioral disturbances exhibited ongoing restlessness, agitation, and insomnia, including attempts to stand unassisted and episodes of hitting and kicking. Despite these behaviors and the absence of an as needed medication order, nursing staff did not notify the physician as required by facility policy and care plan directives, resulting in a deficiency.
A resident with severe cognitive impairment and behavioral disturbances was found physically restrained in a wheelchair with a sheet tied around their waist and secured to the chair. The resident had been restless and repeatedly attempted to stand unassisted during the night. A nursing assistant, concerned about fall risk, tied the sheet to prevent the resident from getting up, despite knowing restraints are not permitted. Facility policy prohibits such use of restraints, and the incident was confirmed through documentation and staff interviews.
Failure to Act Timely on Therapy-Recommended Transfer Status Change
Penalty
Summary
The facility failed to act timely when therapy recommended a change in transfer status for a resident with altered mental status and dementia. The admission MDS identified a BIMS score of 10, no behaviors, and partial assistance needed with transfers. The resident care plan identified fall risk and self-care deficit, with interventions for call light access, two-person assist with transfers using a rolling walker, and ambulation with rehab only. The physician order review did not identify an order directing transfer status, and the record showed therapy changed the resident’s transfer status to one assist on 5/1/26, with the process being to enter the change into the EMR queue for nursing to obtain updated physician orders. The resident had a witnessed fall on 5/2/26 while a NA transferred the resident into a wheelchair and the resident’s foot became caught in the wheelchair. The resident lost balance and fell to the floor, sustaining a laceration above the right eyebrow, abrasions to the right knee and right thumb, and a headache, and was transferred to the hospital. The resident returned with six stitches to the right eyebrow. The facility reportable event summary later stated the resident was wearing non-skid socks and that the fall occurred when the resident stood up and quickly turned left during the transfer, causing the right foot to catch on the wheelchair. Interviews with the NA, DOR, and DNS identified that staff were treating the resident as one assist for transfers, but the interview failed to identify where that information came from or whether the therapy recommendation had been entered into the EMR queue and acted upon by nursing. A policy for acting upon therapy recommendations was not provided.
Unsafe Transfer Leading to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a resident with altered mental status and dementia, who was identified on the care plan as needing two-person assistance with transfers and ambulation only with rehab, was transferred safely and in accordance with the plan of care. The admission MDS showed a BIMS score of 10, indicating moderately impaired cognition, and the resident had a care plan for fall risk and self-care deficit with interventions to keep the call light within reach and provide two-person assist with transfers using a rolling walker. The physician order review did not identify an order for transfer status, and the resident was later found to have been transferred by a nurse's aide without a second staff member. During the transfer from bed to wheelchair, the resident stood up quickly, turned left, caught a foot on the front of the wheelchair, lost balance, and fell to the floor. The resident sustained a laceration above the right eyebrow, abrasions to the right knee and right thumb, and complained of a headache, then was sent to the hospital and returned with six stitches to the eyebrow laceration. The facility's reportable event summary stated the resident was wearing non-skid socks and described the fall as occurring during an abrupt quick turn while being transferred to be toileted; the nurse's aide stated she believed the resident required only one-person assist and did not use a gait belt because it was not in the plan of care. The Director of Rehabilitation stated the resident required one-person assist to stand and pivot and said a gait belt could have prevented the fall, while the Director of Nursing confirmed the care plan directed two-person transfers and that the resident had no contraindication to gait belt use.
Failure to Safeguard Resident Cash Stored in Safe
Penalty
Summary
The facility failed to safeguard a resident's personal valuables when cash money stored in the facility safe went missing. The resident had diagnoses of dementia, depression, and an anxiety disorder, and the admission MDS identified poor decision-making skills regarding tasks of daily living and a need for staff assistance with activities of daily living. Nursing documentation stated that on 9/4/25 a nurse aide found $20 in the resident's brief and later found $340 in cash hidden in soiled bedding along with three checkbooks. The $20 was left with the resident, while the $340 and checkbooks were placed in a biohazard bag and then locked in the nursing unit narcotic box safe until the business office opened. The facility incident report stated the cash and checkbooks were later placed into the facility's locked safe with the Administrator present to safeguard the resident's belongings. On 9/10/25, the money was found missing from the safe when it was opened by the Business Office Manager with the Assistant Biller present. Interviews identified that the Business Office Manager and Assistant Biller typically kept the safe key hidden in a pen holder on a desk in the office, and on the day the money was discovered missing, the office door was left open while they attended a meeting because a Customer Service Liaison was working in the office and did not have a key. The investigation determined the key had been left unsecured, and the Administrator stated the resident's money and checkbooks were inside a biohazard bag in the safe when the loss was discovered.
Failure to Confirm Receiving Facility Acceptance and Send Discharge Summary Before Transfer
Penalty
Summary
The facility failed to ensure the receiving provider accepted Resident #4 prior to transfer and failed to provide the receiving health care facility with the resident’s discharge summary before arrival. Resident #4 had diagnoses including anoxic brain damage, dementia with behavioral disturbance, fracture of the upper end of the left humerus, atrial fibrillation, malignant neoplasm of the prostate, and dysphagia. The admission MDS identified moderately impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and a need for moderate assistance with personal hygiene, bed mobility, ambulation, and transfers. The care plan identified a goal of discharge to the community and noted the resident wished to return to the community with a spouse. The record showed the resident’s spouse was notified of a NOMNC and requested an appeal. After the appeal was lost, the spouse stated a second-level appeal had been filed and planned to pick the resident up, while social services were to arrange home care. On the next day, staff documented concerns from another person that the spouse could not provide the needed care, and transportation was arranged for the resident to go to a short-term hospital. APRN documentation stated the resident needed discharge with 24-hour care, could not care for himself/herself, and was at high risk for falls and rehospitalization. The resident was then transferred to the hospital. Interviews showed the social worker did not contact the receiving health care institution to confirm the resident’s admission and did not contact, convey, or electronically transmit the discharge summary before the resident left the facility. The administrator could not provide documentation showing the facility confirmed the discharge destination or that the discharge summary was provided to the receiving institution before transfer. A supervisor reported that after the resident had already left, a nurse at the receiving institution called asking why the resident had been sent there and requested a copy of the discharge summary. Facility policy directed staff to notify the receiving facility when a transfer was made and identified nursing services as responsible for preparing the discharge summary and post-discharge plan.
Failure to Obtain Physician Order for Discharge
Penalty
Summary
The facility failed to obtain a physician's order for discharge for one resident who was reviewed for discharge. The resident had diagnoses including anoxic brain damage, dementia with behavioral disturbance, fracture of the upper end of the left humerus, atrial fibrillation, malignant neoplasm of the prostate, and dysphagia. The admission MDS identified moderately impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and a need for moderate assistance with personal hygiene, bed mobility, ambulation, and transfers. The MDS also identified the resident's goal for discharge as returning to the community. The care plan documented the resident's wish to return to the community with a spouse and included interventions for pre-discharge planning and community resource arrangements. Nursing and APRN notes documented discussions about the resident's discharge situation, including concerns that the spouse could not provide the needed care, that the resident needed 24-hour care, and that transportation was arranged for transfer to a hospital. The resident was transferred to the hospital, but review of the clinical record and interview with the DNS failed to identify documentation that a physician's order was obtained for the discharge. The DNS stated that the charge nurse should ensure a physician's order is obtained for discharge and could not explain why one was not obtained. The facility policy stated that nursing services is responsible for obtaining orders for discharge.
Failure to Notify Physician of Resident's Behavioral Changes
Penalty
Summary
A deficiency occurred when nursing staff failed to notify the physician regarding a resident who exhibited significant behavioral changes, including restlessness, agitation, and insomnia. The resident, who had diagnoses of dementia with behavioral disturbance and adjustment disorder, was documented as being restless, attempting to get out of a wheelchair, and displaying behaviors such as hitting and kicking. Despite these behaviors being recorded over multiple shifts and the care plan directing staff to monitor and document such symptoms, the nurse on duty did not contact the on-call provider to report the resident's condition or to obtain an as needed medication order for agitation or insomnia. Interviews with facility staff, including the nurse, nursing assistant, physician, and Director of Nursing Services, confirmed that the expectation was for the nurse to notify the physician when a resident without an as needed medication order exhibited significant behavioral symptoms. The facility's policy also required physician notification for significant changes in a resident's physical, emotional, or mental condition. However, the nurse chose not to notify the physician, believing the resident could be calmed without additional medication, which resulted in the deficiency.
Resident Restrained with Sheet in Wheelchair
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia with behavioral disturbances was found physically restrained in a wheelchair with a sheet tied around their waist and secured to the back of the wheelchair. The resident had been exhibiting restlessness, agitation, and attempts to stand unassisted throughout the night. Nursing documentation and staff interviews confirmed that the resident was up most of the night, was unable to remain in bed, and was considered a fall risk due to these behaviors. During the night shift, a nursing assistant reported attempting to place the resident in bed multiple times without success, and ultimately decided to tie a flat sheet around the resident's waist and secure it to the wheelchair to prevent falls while he completed his rounds. The nursing assistant acknowledged awareness that physical restraints are not permitted but felt it was necessary to prevent the resident from falling. The nurse on duty was informed that a sheet was being placed around the resident but stated she did not see the sheet tied as a restraint until later, when another nurse discovered the resident restrained in the dining room. Facility documentation, including the restraint policy, clearly defined physical restraints as any device or material that restricts freedom of movement and cannot be easily removed by the resident. The use of the sheet in this manner met the definition of a physical restraint, and the facility's policy prohibits such practices. The incident was confirmed through interviews, documentation, and direct observation, establishing that the resident was not free from physical restraint as required.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Southbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pomperaug Woods Health Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Springs At East Hill, The | 2 mi | — | 0 | 0 |
| River Glen Health Care Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Middlebury | 5.4 mi | ★★★★★ | 1 | 0 |
| Apple Rehab Watertown | 7.7 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.