Federal inspectors found immediate jeopardy conditions at New London Sub-Acute and Nursing in March 2025, citing failures in abuse reporting, infection control, and staff training that put residents at risk of harm.
The abuse allegation surfaced during a March 18 interview when Resident #43 told inspectors that LPN #7 had pushed the resident onto a bed from a wheelchair in early January. The resident said LPN #7 was alone in the room despite care plans requiring two staff members present at all times, and when the resident started yelling for help, LPN #7 "grabbed the phone out of his/her hand and threw it across the room."
The resident "experienced great humiliation over the event and continued to be afraid of LPN #7," according to the inspection report. LPN #7 continued providing care to the resident after the alleged incident.
Director of Nursing Services initially told inspectors he had completed an investigation and reported the incident to the state. But when pressed for documentation on March 19, he could produce only an undated, unsigned summary that he admitted creating the day before — not at the time of the alleged January 3 incident.
The summary contained multiple factual errors about the resident, including wrong admission date, wrong age, and wrong cognitive assessment scores. It also contradicted the resident's account, claiming the resident "wanted to be changed for incontinence care" when LPN #7 later told inspectors the resident had refused care twice during his shift.
LPN #7 confirmed key details of the resident's account, telling inspectors he removed the phone from the resident's hand during incontinence care and "told Resident #43 he/she could call for help when he was done." He said he made a late entry in nursing notes two days after the incident because the DNS "advised him to do so to protect himself."
The Administrator was aware of the abuse allegation but failed to ensure it was reported to the state agency, inspectors found. The facility finally submitted a reportable event form on March 20 — but it contained more false information, incorrectly listing the incident as "resident to resident abuse" rather than staff-to-resident abuse.
Nobody had.
The facility's infection control failures created additional risks for residents. Staff caring for Resident #96 failed to recognize a dangerous drug-resistant infection for three days after laboratory results came back positive, leaving the resident on inadequate precautions.
The lab called the facility on March 17 to report Resident #96 tested positive for Extended-Spectrum Beta-Lactamase, a multi-drug resistant organism requiring strict isolation protocols. But nursing staff failed to review the results or notify the infection preventionist until March 20.
"The MDRO was not identified by any staff until this morning when she reviewed the results and changed Resident #96 to the appropriate contact precautions," the infection preventionist told inspectors, acknowledging the three-day delay.
During those three days, staff continued using lesser precautions designed for routine care rather than the strict isolation required for active drug-resistant infections.
Inspectors observed multiple infection control violations throughout the facility. Two nursing assistants provided incontinence care to a resident on enhanced barrier precautions while wearing gloves but no gowns, despite clear signage directing both. The assistants said they were unaware the resident required special precautions.
A licensed practical nurse performed wound care on another resident, changing gloves multiple times without washing hands between changes. When questioned, she said hand hygiene between glove changes was only required "when there was an active infection, otherwise it was not necessary." The infection preventionist contradicted this, confirming hand hygiene was required between all glove changes.
Physical therapy staff walked into a room housing a resident with active MRSA in the sputum without any protective equipment. The room displayed incorrect signage for enhanced barrier precautions rather than the droplet precautions required for respiratory MRSA. Only when a nurse spotted them leaving with the resident did staff realize the error and stop the transport.
The facility's training failures compounded these problems. Thirty-one employees — nearly 20 percent of staff — had received no abuse and neglect training despite facility policy requiring annual education. The Staff Development nurse acknowledged she was "responsible for ensuring all employees received the mandatory in-service training" but could not explain why so many staff lacked required training.
The abuse training that was provided omitted key federal requirements. It failed to address screening residents for abuse, identifying physical indicators of abuse, mandated reporting procedures, or how to report allegations without fear of reprisal. The training also lacked content on resident exploitation, chemical restraints, recognizing staff burnout that increases abuse risk, and dementia management for abuse prevention.
"Someone didn't take the time to read the policy when creating the education," the Staff Development nurse told inspectors, admitting she had never reviewed the facility's abuse policy despite being responsible for training accuracy.
The facility operates without basic compliance infrastructure. Administrators acknowledged having no compliance and ethics program, no compliance officer, and no ethics policy. Staff receive no training on ethical concerns or how to report them confidentially.
Quality assurance meetings excluded the infection preventionist for six consecutive months in 2024, violating federal requirements. The administrator blamed staffing issues, saying the previous infection preventionist resigned in August 2024 and the replacement wasn't hired immediately.
Record-keeping problems extended beyond the abuse case. The DNS wrote false documentation about a bathroom incident involving Resident #46, claiming he personally responded to assess the resident and that a nursing assistant used a gait belt to safely lower the resident to the ground. Both the nursing assistant and the registered nurse who actually responded contradicted this account, saying the DNS never appeared at the scene and no gait belt was used.
The facility assessment claims staff receive behavioral health education for the approximately 50 residents with psychiatric needs among the 102-108 total census. But review of in-service calendars from March 2024 through March 2025 found no scheduled behavioral health training. Only 19 of 164 employees attended a single personality disorders session in March 2025.
The Administrator acknowledged meeting weekly with the DNS but kept no records of these conversations in meeting minutes, personal notes, or emails. He was responsible for signing reportable events but failed to ensure the January 3 abuse allegation was ever submitted to state authorities.
Resident #43 remains fearful of the LPN who allegedly threw the phone, with the staff member continuing to provide care despite the unresolved allegation that was hidden from state oversight for nearly three months.
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
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