Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Lutheran Home Of Southbury Inc
SOUTHBURY, CT · 120 certified beds · Last Life Safety survey June 17, 2025
CMS Certification Number 075371 · first certified October 1991
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CT
22 citations — more than 83% of the 191 certified nursing homes in CT. Compared within CT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 6 months from now. This facility’s last Life Safety survey was June 2025. Facilities in CT are typically surveyed 21–28 months after the last one (median 24), measured over 181 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 22 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in CT, and nationally. Surveyors differ markedly between states, so the CT figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in CT | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 20, 2021 | 2 |
| August 29, 2023 | 12 |
| June 17, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 2 | 2025-06-17 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2023-08-29 |
| K-0344 | Have an alternate power supply for its alarm system. | 2 | 2025-06-17 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-08-29 |
| E-0037 | Establish staff and initial training requirements. | 2 | 2025-06-17 |
| K-0711 | Provide a written emergency evacuation plan. | 2 | 2025-06-17 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 2 | 2025-06-17 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-08-29 |
What the citations cover
- Miscellaneous Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 4
- Smoke Deficiencies 4
- Other 3
| Category | Citations |
|---|---|
| Miscellaneous Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 17, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0344 | Have an alternate power supply for its alarm system. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (July 17, 2025) |
August 29, 2023 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (October 11, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0344 | Have an alternate power supply for its alarm system. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (October 11, 2023) |
July 20, 2021 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 31, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 31, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.