New London Sub-Acute: Care Plan Review Failure - CT
The resident, identified in inspection records only as Resident #59, had a care conference in October 2024. The next one was due in January 2025. It never happened.
The resident's care plan, still in effect when inspectors reviewed it on March 24, 2025, described a person with severe cognitive impairment who needed help setting up meals, required supervision with personal hygiene, and had a significant communication barrier rooted in profound hearing loss. The plan called for staff to encourage the resident to keep expressing thoughts and feelings. Whether that guidance still reflected the resident's actual condition five months later, nobody at the facility had formally assessed.
The process for scheduling these quarterly conferences ran through at least three people. The MDS Coordinator, Licensed Practical Nurse #15, was responsible for generating a list of residents due for review based on their assessment dates. She gave that list to an administrative assistant, who called families and coordinated dates with Social Worker #2. When inspectors asked LPN #15 on March 24 to produce the list she had submitted for January 2025 scheduling, she could not find it.
Social Worker #2, interviewed the same morning at 9:00 a.m., said Resident #59 had simply not appeared on her list of residents to schedule in January. She attributed the omission to an error by the MDS Coordinator. The conference, she said, had been missed due to oversight.
By the time inspectors were on site, the resident had been added back to the scheduling queue for the week of March 25 through March 27, 2025, the same days the inspection was wrapping up.
The violation was cited at the minimal harm level, meaning inspectors did not find evidence the lapse had caused direct physical injury. But the care conference is not a formality. For a resident with severe cognitive impairment, the quarterly meeting is one of the few structured moments when staff, family, and care coordinators sit together and ask whether the current plan still fits the person in front of them. Resident #59's documented communication challenges, rooted in bilateral sensorineural hearing loss and compounded by dementia, made that kind of structured review more consequential, not less. A resident who cannot easily signal distress, advocate for changes, or follow a conversation in a noisy hallway depends on that process working.
The inspection covered one resident out of five sampled for unnecessary medication review. The deficiency finding was narrow in scope, but the mechanism it exposed was not. The scheduling system relied on a list that one coordinator generated, handed off, and apparently never confirmed was acted upon. Nobody had a backup check. When the list was wrong, or lost, or never made it to the right desk, the resident simply disappeared from the queue.
The facility's own policy required quarterly care plan updates to be completed no later than seven days after the relevant MDS assessment. The October conference put the next deadline somewhere in January. January passed. February passed. March arrived with federal inspectors, and only then did Resident #59 get added back to the list.
A resident with dementia cannot follow up on a missed meeting. Cannot call the social worker's office. Cannot ask why nobody has checked in. The care conference exists precisely because that resident cannot do those things. When the scheduling list has an error and nobody is watching for it, five months can pass in silence.
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.
The resident, identified in inspection records only as Resident #59, had a care conference in October 2024.
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.