New London Sub-Acute: Oxygen Given Without Order - CT
The resident, identified in inspection records only as Resident #50, had a physician's order for oxygen that ran through March 10, 2025. After that date, the order was never renewed. The oxygen kept flowing anyway.
When a surveyor raised the issue on March 18, the facility's RN supervisor acknowledged the problem immediately. She said continuous oxygen should not have been administered without a physician's order, and that it would have been her responsibility, or the charge nurse's, to get one from the provider. She said she wasn't sure why no one had.
Seventeen minutes after that conversation, at 10:45 a.m., a new order was obtained.
What inspectors found next made the lapse harder to dismiss as paperwork. A nurse practitioner examined Resident #50 that same afternoon and documented what she found: oxygen saturation in the high 70 percent range on room air, a respiratory rate that was elevated, a heart rate in the 110s while the resident sat in a wheelchair in the common room. The resident was grunting and short of breath. When placed on four liters of supplemental oxygen, saturation climbed to 99 percent. The NP diagnosed atypical pneumonia and ordered oxygen continued to keep saturation above 92 percent.
The director of nursing, interviewed the following day, confirmed that Resident #50 had needed and received continuous oxygen for several weeks. She said the order simply hadn't been renewed after March 10 due to, in her words, "poor follow through." She identified the RN supervisor as the person responsible for obtaining the renewal.
The inspection report rated the violation at minimal harm or potential for actual harm, affecting few residents.
That rating captures something, but not everything. A resident whose oxygen saturation was sitting in the high 70s, whose heart was racing, who was grunting for breath in a common room wheelchair, had been receiving a treatment that technically had no authorization for at least eight days. The treatment was the right one. The authorization had simply been allowed to lapse, and no one had noticed, or acted, until a surveyor asked.
Oxygen saturation in the high 70 percent range is a medical emergency in most clinical contexts. Normal saturation runs between 95 and 100 percent. The 70s indicate the body's tissues are not receiving adequate oxygen, a condition that can cause organ damage and, sustained long enough, death. Whether Resident #50's saturation had been that low for hours or days before the NP's exam on March 18 is not documented in the inspection record.
The facility's own oxygen administration policy, undated, required a physician's order for continuous oxygen and directed licensed clinicians to verify that such an order existed. No one had verified it after March 10.
New London Sub-Acute and Nursing is located at 90 Clark Lane in Waterford. The inspection was completed March 27, 2025.
What the record does not show is whether anyone checked on Resident #50 between March 10, when the order expired, and March 18, when the surveyor asked about it, and noticed the resident's breathing, or the missing paperwork, and did nothing. The DNS said it was poor follow through. The NP's notes from the afternoon of March 18 describe a resident in acute respiratory distress, grunting in a wheelchair, heart racing, lungs failing to pull in enough oxygen to keep saturation out of the danger zone.
The order took seventeen minutes to get once someone asked for it.
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.
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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.
The resident, identified in inspection records only as Resident #50, had a physician's order for oxygen that ran through March 10, 2025.
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.