New London Sub-Acute: Falsified Incident Records - CT
None of it matched what the nursing assistant or the floor nurse said actually happened.
The incident involved Resident 46, who was being helped to the bathroom on November 16, 2024, by a nursing assistant identified in the inspection report as NA 5. According to NA 5, the resident had responded to a call light urgently requesting bathroom assistance. NA 5 went without a gait belt. When Resident 46 stood up and reached for a pull bar, she lost her grip and the right side of her head hit the wall. NA 5 stayed with the resident through the rest of the trip to the toilet, then wheeled her to the nurses' station to report what had happened to RN 3.
The resident did not fall. She did not lose consciousness. She denied pain, and no marks or bruises were observed. RN 3 initiated vital signs and neurological monitoring, and notified the family and physician. By the standard of nursing home incidents, it was minor.
What happened next was not.
Two days later, the director of nursing entered a late progress note, dated back to the time of the incident. The note described him being called to Resident 46's room, responding in person, and observing that NA 5 had used a gait belt to lower the resident safely to the ground before helping her back to the toilet. The note read as a firsthand account of a situation the director had managed directly.
When inspectors interviewed the director of nursing on March 19, 2025, four months after the incident, he said he had responded to the bathroom incident but could not recall the details. He could not explain whether he had actually gone to the room, as his note stated, or whether he had written the note based on conversations with NA 5 and RN 3. He told inspectors he would seek clarification from both of them.
NA 5 told inspectors she had never been interviewed by the director of nursing about the incident. Not that day, not afterward.
RN 3 confirmed she had assessed Resident 46 after the bathroom accident. She told inspectors directly that the director of nursing was not present when she did the assessment, and that Resident 46 had not been lowered to the ground with a gait belt, as the director's note claimed.
The gait belt detail matters. NA 5 had gone to assist Resident 46 without one, a fact she acknowledged to inspectors without apparent hesitation. The director's note transformed that into a controlled, equipment-assisted lowering to the floor, a version of events that would have reflected better on the facility's safety practices and, implicitly, on the nursing assistant's conduct.
The director could not explain where that version came from.
Inspectors cited the facility for failing to maintain accurate medical records, noting that the director's documentation "failed to describe an accurate representation of Resident 46's incident and actual experience in the bathroom." The violation was tagged at a level of potential for minimal harm, the lower end of the federal harm scale, in part because Resident 46 was not seriously injured.
What the inspection report leaves unresolved is how a director of nursing writes a detailed, first-person account of an incident he may not have witnessed, attributes specific actions to a staff member who says those actions didn't happen, and four months later cannot explain his own notes.
Resident 46, who bumped her head on a bathroom wall and was back in her wheelchair within minutes, ended up at the center of a documentation dispute she had no part in creating.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New London Sub-acute and Nursing from 2025-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
NEW LONDON SUB-ACUTE AND NURSING in WATERFORD, CT was cited for violations during a health inspection on March 27, 2025.
None of it matched what the nursing assistant or the floor nurse said actually happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.