Inspection Reports for Lutheran Home Of Southbury Inc
990 Main St N, Southbury, CT 06488, CT, 06488
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 21, 2025, found the facility in compliance with all regulations and no new deficiencies were identified. Earlier inspections showed a mixed record with deficiencies related primarily to infection control, medication management, resident care, and food service safety. Complaint investigations from 2019 and 2025 resulted in substantiated deficiencies involving nursing assessments, medication errors, and food service practices, while most other complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have improved over time, correcting prior deficiencies and maintaining compliance in the latest review.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
99% occupied
Based on a August 2025 inspection.
Census over time
Inspection Report
Monitoring
Census: 119
Capacity: 120
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
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.
Findings
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.
Deficiencies (1)
Previous deficiencies cited on 2025-06-17
Report Facts
Deficiencies cited: 10
Licensed Bed Capacity: 120
Census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jackson | Administrator | Personnel contacted during inspection |
| Siobhan O'Neill | Survey Team Leader | Survey team leader conducting inspection |
| Judith Birtwistle | Supervisor | Supervisor overseeing inspection |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 120
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
A complaint investigation survey was conducted to determine compliance with 42 CFR Part 483 requirements for long term care facilities.
Complaint Details
Complaint Investigation Survey, ACT Reference Numbers CT # 35377 and #42744.
Findings
Deficiencies and/or violations were cited as a result of this survey.
Report Facts
Licensed Bed Capacity: 120
Census: 111
Inspection Report
Renewal
Census: 109
Capacity: 121
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
The visit was a desk audit conducted as part of the licensing inspection process on December 3, 2024.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ziad Baroody | Administrator | Administrator contacted during the inspection. |
| Reba Stoddard | NC | Report submitted by. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 120
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint #37610.
Complaint Details
Complaint investigation #37610 was conducted and found no violations; the complaint was not substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ziad Baroody | LHHA | Personnel contacted during the inspection |
| Brenda Cash | RN | Personnel contacted during the inspection |
| Debbie Wade | RN Corporate Nurse | Personnel contacted during the inspection |
Inspection Report
Plan of Correction
Census: 109
Capacity: 120
Deficiencies: 0
Date: Nov 9, 2021
Visit Reason
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.
Findings
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.
Report Facts
Licensed Bed Capacity: 120
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Kolosky | RN, MSN, NC | Representative conducting the desk audit and approving issuance of license |
| Inna Glenbovitch | RN, DNS | Personnel contacted by telephone on 11/9/21 |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Aug 24, 2021
Visit Reason
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.
Findings
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.
Deficiencies (4)
NA #1 did not wear eye protection or gloves as directed by the precautions sign while caring for a COVID-19 exposed resident.
Overflowing PPE bin with soiled gowns exposed and improperly stored.
Facility failed to provide a policy for handling linens and reusable gowns for COVID-19 residents.
Lack of signage or tape markings to alert staff/visitors entering areas requiring PPE.
Report Facts
Completion Date: Oct 5, 2021
Weekly audits: 10
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas-Markure | Supervising Nurse Consultant | Author of the notice letter regarding the survey and violations |
Inspection Report
Renewal
Deficiencies: 7
Date: Jul 20, 2021
Visit Reason
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.
Findings
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 (7)
Failure to notify physician when resident refused an ordered treatment related to ted stockings.
Failure to provide treatment for lower extremity edema.
Failure to implement measures to prevent falls as documented in the plan of care.
Failure to maintain medication storage rooms in a secure manner.
Failure of dietary staff to wear hair restraints in the kitchen.
Failure to maintain appropriate infection control related to hand washing.
Failure to obtain and document pneumococcal and Prevnar 13 vaccination history and administration.
Report Facts
Residents reviewed for specific deficiencies: 1
Residents reviewed for falls deficiency: 8
Medication storage rooms observed: 3
Dietary aides observed: 3
Residents reviewed for immunizations: 5
Completion dates for corrections: Aug 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gendron | Administrator | Named as recipient of the report and signer of the plan of correction |
| Norma Schuberth | Supervising Nurse Consultant | Author of the notice letter |
Inspection Report
Annual Inspection
Census: 115
Capacity: 120
Deficiencies: 7
Date: Jul 20, 2021
Visit Reason
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.
Findings
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.
Deficiencies (7)
Facility failed to notify the physician when Resident #24 refused an ordered treatment (ted stockings).
Facility failed to provide treatment for lower extremity edema for Resident #24 as ordered.
Facility failed to implement fall prevention measures as documented in the plan of care for Resident #37.
Medication rooms on C-2 North and C-2 South units were unsecured.
Dietary staff failed to wear hair restraints (beard guard and hair net) while in the kitchen.
Facility failed to maintain appropriate infection control related to hand washing; staff failed to wash hands after glove removal and between resident care.
Facility failed to obtain pneumococcal and Prevnar 13 vaccination history and failed to administer Prevnar 13 vaccine to Resident #24.
Report Facts
Deficiencies cited: 7
Census: 115
Total Capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Placed orders for Resident #24 and was not notified of treatment refusals |
| NA #3 | Nurse Aide | Observed failing to perform proper hand hygiene after glove removal |
| LPN #2 | Licensed Practical Nurse | Forgot to close medication room door |
| RN #2 | Registered Nurse | Observed medication room unsecured while preparing narcotics |
| DA #1 | Dietary Aide | Observed with facial hair without beard guard in kitchen |
| DA #2 | Dietary Aide | Observed without hair net in kitchen |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 120
Deficiencies: 0
Date: Jul 6, 2021
Visit Reason
The inspection visit was conducted as a complaint investigation, referenced by complaint investigation number 30344.
Complaint Details
Complaint investigation number 30344 was conducted and found no violations.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gendron | Administrator | Personnel contacted during the inspection. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 20, 2020
Visit Reason
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.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Renewal
Census: 114
Capacity: 120
Deficiencies: 2
Date: Mar 12, 2020
Visit Reason
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.
Findings
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.
Deficiencies (2)
Facility failed to discard expired Intravenous (IV) Solutions found in the Emergency Medication Storage System (Cubex) on C2 North medication room.
Facility failed to maintain the kitchen in a sanitary manner, including issues such as deep standing water below the three compartment pot sink, accumulation of dried debris on a cart, ice accumulation in the walk-in freezer, and unclean food preparation areas.
Report Facts
Inspection dates: 4
Licensed bed capacity: 120
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irene Glensovitch | DNS | Personnel contacted during inspection |
| Kevin J. Gendron | Administrator | Personnel contacted during inspection and recipient of inspection notice |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 12, 2020
Visit Reason
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.
Findings
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.
Deficiencies (2)
Facility failed to discard expired Intravenous (IV) Solutions in the Emergency Medication Storage System (Cubex).
Facility failed to maintain the kitchen in a sanitary manner, including standing water under the three compartment pot sink, accumulation of dried debris on a cart, and unclean food preparation areas and equipment.
Report Facts
Medication expiration dates: 2
Audit frequency: 3
Completion date: Nov 10, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gendron | Administrator | Recipient of the notice letter. |
| Director of Nurses | Named as ultimately responsible to ensure compliance with medication storage correction. | |
| Director of Food Services | Named as responsible for food service department sanitation and compliance. | |
| Staff Development Coordinator | Responsible for education on correct expiration date entry for IV solutions. |
Inspection Report
Follow-Up
Census: 118
Capacity: 120
Deficiencies: 0
Date: Jun 14, 2019
Visit Reason
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.
Findings
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.
Report Facts
Licensed Bed: 120
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cara Urban | BSN | Signed report and noted in findings |
Inspection Report
Follow-Up
Census: 118
Capacity: 120
Deficiencies: 0
Date: Jun 14, 2019
Visit Reason
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.
Findings
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.
Report Facts
Licensed Beds: 120
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cara Urban | BSN | Reported and signed the follow-up desk audit report |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 25, 2019
Visit Reason
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.
Findings
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.
Deficiencies (4)
Failure to ensure a Registered Nurse (RN) assessment was completed timely when a change in skin condition was identified for Resident #411.
Failure to implement a splinting device in accordance with physician's orders for Resident #72.
Failure to ensure residents are free of significant medication errors; specifically, an anticonvulsant medication was not administered as ordered for Resident #28.
Failure to ensure food was served in accordance with professional standards for food service safety; dietary aide with beard was not wearing a beard restraint.
Report Facts
Deficiencies cited: 4
Dates of unannounced visits: February 19, 20, 21, and 25, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Named in findings related to skin condition assessment and nursing orders | |
| RN #1 | Infection Control Nurse/Wound Nurse | Named in findings related to skin condition assessment and communication |
| RN #4 | Named in findings related to skin condition assessment | |
| NA #5 | Nurse Aide | Named in findings related to splinting device use |
| RN #5 | Registered Nurse | Named in findings related to splinting device use and care card updates |
| OT #1 | Occupational Therapist | Named in findings related to splinting device recommendations |
| Dietary Aide #1 | Dietary Aide | Named in findings related to failure to wear beard restraint |
| Assistant Dietary Manager | Named in findings related to beard restraint policy and oversight | |
| Director of Nursing | Director of Nursing | Named in findings related to skin condition assessment and medication transcription error |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 120
Deficiencies: 4
Date: Feb 19, 2019
Visit Reason
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.
Complaint Details
Complaint investigation involved multiple complaints (#23606, 24139, 24204, 24916). Violations were substantiated as indicated by citations and violation letters issued.
Findings
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.
Deficiencies (4)
Failure to ensure a Registered Nurse (RN) assessment was completed timely when a change in skin condition was identified for Resident #411.
Failure to implement a splinting device in accordance with physician's orders for Resident #72.
Failure to ensure anticonvulsant medication was administered as ordered resulting in seizure activity for Resident #28.
Failure to ensure food was served in accordance with professional standards for food service safety; dietary aide identified with a full beard without beard restraint.
Report Facts
Licensed Bed Capacity: 120
Census: 119
Inspection Dates: 4
Citation Number: 2019
Plan of Correction Completion Date: Apr 2, 2019
Residents Audited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gendron | Administrator | Named as personnel contacted during the inspection. |
| Brenda Cash | Named as personnel contacted during the inspection. | |
| Cher Michaud | Supervising Nurse Consultant | Author of the inspection report and correspondence. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 30, -0001
Visit Reason
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.
Complaint Details
Complaints #23606, 24139, 24204, 24916 were investigated as part of the visit.
Findings
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.
Deficiencies (4)
Failure to ensure a Registered Nurse (RN) assessment was completed timely when a change in skin condition was identified for Resident #411.
Failure to implement a splinting device in accordance with physician's orders for Resident #72.
Failure to ensure an anticonvulsant medication was administered as ordered for Resident #28, resulting in a medication error.
Failure to ensure food was served in accordance with professional standards for food service safety; Dietary Aide #1 was observed with a full beard and mustache without a beard restraint.
Report Facts
Completion date for plans of correction: 2019
Number of residents audited weekly and monthly for skin condition changes: 5
Number of residents audited weekly and monthly for splinting device compliance: 5
Number of residents audited weekly and monthly for anticonvulsant medication accuracy: 3
Number of months for dietary beard restraint observations: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Signed letter directing response to deficiencies |
| Kevin Gendron | Administrator | Facility administrator addressed in the report |
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Jul 20, 2021
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