New London Sub-Acute: Meal Supervision Failure - CT
She was wrong, and the care plan said so in plain terms.
Resident #84, a patient at New London Sub-Acute and Nursing on Clark Lane, required one-on-one supervision during every meal. His care plan directed staff to provide setup, cueing, and continuous oversight while he ate. An occupational therapist had determined he needed help and encouragement to eat at all. He had dysphagia, a swallowing difficulty that put him at risk of choking.
None of that reached the aide who served him breakfast that morning.
When inspectors interviewed Nursing Assistant #6 on March 19, she told them she had placed the tray in front of Resident #84 and left to serve other trays on another hallway without alerting anyone that the resident was now eating alone. She said she didn't think he needed help. When inspectors asked her to pull up the resident's care card on her tablet to verify that, she couldn't find it. She had to ask the floor nurse for help.
What the care card said, once located, was unambiguous. One-to-one assist with meals. Supervision required.
NA #6 told inspectors she should have known the resident's care information before she ever picked up that tray.
LPN #1, the nurse on duty, told inspectors the responsibility fell on NA #6 to know her assignment or ask if she was uncertain. She said she would need to review NA #6's assignment with her again. The Director of Nursing, interviewed later that afternoon, said the aide or a nurse should have stayed with Resident #84 throughout the meal, or the resident should have been brought to a common area where staff could watch him. He said he couldn't explain why NA #6 had been unable to access the resident's care information on her tablet, and that he would need to speak with her and provide further training.
The occupational therapist who had set the mealtime guidelines, OT #1, said she had recently updated those guidelines for the nursing staff on the unit. She could not explain why Resident #84 had still been left alone. She said she would need to provide further education to staff.
Three staff members, a floor nurse, a director of nursing, and an occupational therapist, each responded to the same lapse with a version of the same answer: more training would follow. None could account for why a resident with a documented choking risk had been left to eat without anyone in the room.
Inspectors requested a written policy on dining guidelines and meal supervision. None was provided.
The violation was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects the regulatory threshold, not the narrowness of what could have happened. A resident with dysphagia, eating alone, with no one close enough to respond if he began to choke, is not a paperwork problem.
The inspection was completed March 27, 2025. As of the date of that report, the Director of Nursing had not yet explained why the aide could not access a care plan that should have been available on the tablet she carried through the unit every morning.
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: October 31, 2026 · Our methodology
NEW LONDON SUB-ACUTE AND NURSING in WATERFORD, CT was cited for violations during a health inspection on March 27, 2025.
She was wrong, and the care plan said so in plain terms.
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.