Lutheran Home Of Southbury Inc

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

explained although she, the Assistant Biller, and the Administrator were the only ones to have access to the key to the facility safe, the key was left unsecured in a pen holder on a desk in the office when she and the Assistant Biller left for the meeting on 9/10/25. Interview with the Assistant Biller on 9/25/25 at 11:20 AM identified she had last seen the money in the facility safe, which she had placed into the safe with the Administrator present in early September. The Assistant Biller identified the money was first noticed as missing on 9/10/25 after she and the Business Office Manager saw the clear biohazard bag had been opened. Interview and review of the facility incident report with the Administrator on 9/25/25 at 12:05 PM identified at the beginning of September, she witnessed the Assistant Biller place Resident #1's cash money and three (3) checkbooks into the facility safe after nursing found the money and checkbooks on Resident #1. The Administrator indicated Resident #1's money and checkbooks were inside a biohazard bag, which was then placed into the facility's safe and on 9/10/25 at 4:30 PM, she was informed by the Business Office Manager that the money from the biohazard bag was missing. The Administrator explained

she was unable to determine who was responsible for removing Resident #1's money from the safe, Resident #1 was reimbursed and the Customer Service Liaison resigned. Interview with Customer Service Liaison on 9/25/25 at 1:15 PM via phone indicated he/she was not sure what happened to Resident #1's money. Review of the facility Abuse Prevention Program Policy dated 5/25/25 defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of

a resident's belongings or money without the resident's consent and directed that residents had the right to be free from misappropriation of resident property.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lutheran Home of Southbury Inc

990 North Main Street Southbury, CT 06488

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#4. SW #2 indicated Person #2 reported he/she arranged transportation on 9/13/2025 to another health care institution. SW #2 identified that on 9/12/2025, she did not contact the receiving health care institution to confirm Resident #4's admission on [DATE REDACTED]. SW #2 identified on 9/12/2025 and 9/13/2025, she did not contact, convey, or electronically transmit Resident #4's discharge summary to the receiving health care institution or health care provider.Interview with Person #2 on 9/30/2025 at 10:27 A.M. identified on 9/12/2025 he/she received a call from Resident #4's spouse, who reported Resident #4 was scheduled to be discharged on 9/13/2025 from the facility back to the hotel. Person #2 indicated Resident #4's spouse had been recently hospitalized and stated he/she was unable to care for Resident #4. Person #2 indicated Resident #4's spouse asked if he/she could help coordinate transportation to a short-term care hospital on 9/13/2025. Person #2 identified he/she spoke to SW #2 on 9/12/2025 to notify him/her of the arranged transportation on 9/13/2025 to the short-term care hospital.Interview with the Administrator on 9/30/2025 at 11:41 AM identified that on 9/13/2025, when Resident #4 left the facility, he/she had a copy of his/her discharge summary. The Administrator was unable to provide documentation to reflect the facility confirmed Resident #4's discharge destination or that a discharge summary was provided to the receiving health care institution on 9/13/2025. Interview with RN #1 (supervisor) on 9/30/2025 at 1:11 P.M. identified on 9/13/2025 at 4:30 P.M., RN #2 reported Resident #4 was discharged between 12:00 P.M. and 1:00 P.M., with his/her discharge paperwork. RN #1 identified that on 9/13/2025 at approximately 4:30 P.M., she received a call from a nurse at the health care institution asking why Resident #4 was sent there and requested that she send over a copy of Resident #4's discharge summary.Interview with the DNS on 9/30/2025 at 2:10 P.M. identified on 9/12/2025 SW #2 should have contacted the receiving health care institution to confirm Resident #4's admission on [DATE REDACTED] and then sent over Resident #4's discharge summary. The DNS was unable to explain why there was no communication with the receiving health care institution or why the discharge summary was not sent before Resident #4 left the facility.Although attempted, an interview with RN #2 was not obtained.Review of the facility's Transfer or Discharge Emergency Policy dated 12/2021, directed in part, should it become necessary to transfer or discharge to a hospital or other related institution our facility will implement the following procedure: notify the receiving facility that the transfer is being made.Review of the facility's Transfer or Discharge Policy dated 12/2016, directed in part, nursing services is responsible for preparing the discharge summary and post-discharge plan.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lutheran Home of Southbury Inc

990 North Main Street Southbury, CT 06488

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for discharge, the facility failed to obtain a physician's order for discharge.

The findings include:Resident #4 had diagnoses that included 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 Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified Resident #4 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), was frequently incontinent of bowel, occasionally incontinent of bladder, and required moderate assistance with personal hygiene, bed mobility, ambulation, and transfers. The MDS further identified Resident #4's goal for discharge was to be discharged to the community.The care plan dated 9/10/2025 identified Resident #4 wished to return to the community where he/she resided with his/her spouse.

Interventions directed to establish a pre-discharge plan, evaluate progress, revise the plan as needed, make arrangements with required community resources to support independence post-discharge, prepare and give resident/family member/caregivers contact numbers for all community referrals.The nurse's note dated 9/12/2025 at 2:16 P.M. by Licensed Practical Nurse (LPN) #2 (MDS coordinator) identified she and Social Worker (SW) #2 spoke with Person #2 who had concerns about Resident #4 returning to prior living arrangements with his/her spouse secondary to Resident #4 being recently hospitalized , and the spouse unable to provide Resident #4 with the care he/she needed. LPN #2 indicated Person #2 arranged transportation, for Resident #4, to a short-term hospital. LPN #2 indicated that on 9/13/2025, the nursing staff would call Resident #4's spouse to call transportation.APRN #1's note dated 9/12/2025 at 10:31 A.M. identified Resident #4's insurance was requesting a discharge home. APRN #1 identified Resident #4 resided in a hotel with his/her spouse due to homelessness. APRN #1 identified Resident #4 needed to be discharged with 24-hour care because he/she could not care for himself/herself, was at high risk for falls, and was at high risk for rehospitalization.APRN #1's note dated 9/12/2025 at 2:13 P.M. identified that Resident #4 was transferred to the hospital.The nurse's note dated 9/13/2025 at 3:34 P.M. by LPN #3 identified Resident #4 was transferred to the hospital.Interview and clinical record review with the DNS on 9/30/2025 at 2:10 P.M. failed to Identify documentation to reflect a physician's order was obtained when Resident #4 was discharged on 9/13/2025. The DNS identified that when a resident is being discharged ,

the charge nurse should ensure a physician's order is obtained for discharge. The DNS was unable to explain why a physician's order was not obtained to discharge Resident #4. Review of the facility's Transfer or Discharge Policy dated 12/2016, directed in part, that nursing services is responsible for obtaining orders for discharge.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet