Cycle 1
Health 2025-06-17 · Fire 2025-06-17
13 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Southbury, CT
Lutheran Home Of Southbury Inc
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
990 North Main Street, Southbury, CT
(203) 264-9135
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascentria Care Alliance
Operator or chain grouping
Approved since
1991-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing
LPN hours / resident day
0.98
Licensed practical nurse staffing
Aide hours / resident day
2.49
Nurse aide staffing
Weekend hours
3.52
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
87.5%
7.1 pts better
|
93.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.6% |
93.5%
0.1 pts better
|
95.5%
1.9 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.4%
1.4 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
17.1%
17.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.0% |
6.4%
1.6 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
17.3%
4 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.0% |
19.4%
0.4 pts better
|
16.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.3% |
18.1%
3.2 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.0% |
18.4%
13.6 pts worse
|
14.9%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.7%
0.2 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
24.8%
0.3 pts better
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.4%
1.6 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.7% |
70.5%
7.2 pts better
|
81.7%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
11.1%
1.4 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
69.7%
18.3 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
25.0%
2.2 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-29 · Fire 2023-08-29
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2021-07-20 · Fire 2021-07-20
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-06-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-06-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-17
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-17
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-17
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-07-17
E · Potential for more than minimal harm
2023-08-29
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-08-29
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-29
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-10-11
D · Potential for more than minimal harm
2021-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-01
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-08
E · Potential for more than minimal harm
2025-06-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-07-29
E · Potential for more than minimal harm
2025-06-17
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-17
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-02-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-09-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-09-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-06
D · Potential for more than minimal harm
2023-08-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-10
B · Minimal harm
2023-08-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-10
E · Potential for more than minimal harm
2021-07-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-08-31
E · Potential for more than minimal harm
2021-07-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-08-31
Penalties and ownership
What sits behind the stars
Ownership
Ascentria Care Alliance Inc
Operational/Managerial Control · Organization
Baroody, Ziad
Operational/Managerial Control · Individual
Bartholomew, Alexander
Corporate Director · Individual
Bovill, Angela
Operational/Managerial Control · Individual
Bovill, Angela
Corporate Officer · Individual
Cowlagi, Ashish
Corporate Director · Individual
Goodman, Ross
Corporate Director · Individual
Hanscom, Kristin
Corporate Officer · Individual
Khan, Ghulam
Operational/Managerial Control · Individual
Mayo, William
Corporate Director · Individual
Oneal, Gary
Corporate Officer · Individual
Robertson, Keith
Corporate Director · Individual
Russo, Nick
Corporate Officer · Individual
Tappan, Christine
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pomperaug Woods Health Center
Southbury, CT
3-star overall rating with 2-star inspections with abuse icon flag with $20,872 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
River Glen Health Care Center
Southbury, CT
4-star overall rating with 4-star inspections with 15 recent health deficiencies
#3
Complete Care At Middlebury
Middlebury, CT
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out