New London Sub-Acute: Memory Unit Seclusion Violations - CT
No assessment had been done to justify placing them on the secured memory care unit. No physician had signed an order. No resident or family member had been asked to consent. There was no policy governing who could be admitted to the unit at all. When inspectors requested one, it was never produced.
The findings came from a survey that ran nearly two weeks, from March 17 through March 27, 2025. Inspectors observed the unit on all nine days. The entrance and exit required a numeric keypad code. Only staff entered the code, controlling who could leave.
The residents identified in the inspection were Resident #12, #23, #33, #39, #45, #50, #57, #59, #84, #92, and #254. Their clinical records, reviewed by inspectors, contained none of the documentation that would be required before confining someone to a locked unit: no written criteria for placement, no initial assessment, no periodic reassessment to determine whether continued placement was still appropriate, no physician order, and no record that anyone had told residents or their representatives they had the right to independent egress.
When the Director of Nursing was interviewed on March 24, she described the facility's informal standard for placing someone on the unit: a diagnosis of dementia or Alzheimer's and wandering behaviors. That was it. Nothing written. Nothing reviewed. No process by which a resident or their family could weigh in.
Six minutes later, in a follow-up interview that included a registered nurse identified as RN #4, both staff members reviewed the relevant federal regulation on involuntary seclusion. After reading it, they acknowledged what the records had already shown. The residents had been involuntarily secluded.
That word, seclusion, carries specific legal weight. It does not mean a locked door with good intentions behind it. It means confinement without consent, without clinical justification documented in the record, without the procedural protections that exist precisely because people with dementia cannot always advocate for themselves.
The facility's own Director of Nursing confirmed there was no written admission criteria, no initial assessment, no reassessment process, and no documented consent from any of the eleven residents or their representatives. A policy for the secured unit was requested and never provided.
Inspectors classified the harm level as minimal or potential, and noted that some residents were affected. That classification reflects the regulatory framework's language, not a judgment that locking eleven people behind a keypad without legal basis is a minor matter. For a person with dementia who cannot enter a code, cannot call a family member to explain what is happening, and has no documentation in their file establishing why they are there, the locked door is the whole world.
The inspection also noted concerns about the environment within the unit for at least one resident. Staff were expected to be orienting Resident #254 to the time of day, date, and recent events, using his or her name, encouraging socialization, and providing a calendar and clock as part of a care approach across all shifts. Whether those interventions were happening consistently was part of what inspectors were tracking throughout the survey period.
New London Sub-Acute and Nursing is located at 90 Clark Lane in Waterford. The survey was completed March 27, 2025.
What the inspection does not answer is how long this had been the practice. The records that would show an initial assessment, a physician order, a family conversation about what the locked unit meant and whether they agreed to it, those records did not exist. For eleven residents, there was nothing in the file to suggest anyone had ever formally asked.
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 2, 2026 · Our methodology
NEW LONDON SUB-ACUTE AND NURSING in WATERFORD, CT was cited for violations during a health inspection on March 27, 2025.
No assessment had been done to justify placing them on the secured memory care unit.
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.