New London Sub-Acute: Positioning Belt Failures - CT
Inspectors cited New London Sub-Acute and Nursing, located at 90 Clark Lane, following a survey completed March 27, 2025.
The first time inspectors found the problem, a nursing assistant identified as NA #4 acknowledged it was her responsibility to apply the belt when transferring Resident #39 into the wheelchair. She had forgotten. She applied it after the surveyor pointed it out. A licensed practical nurse, LPN #1, confirmed the nursing assistant would have known to apply the belt by checking the resident's electronic medical record.
That same afternoon, the Director of Nursing Services reviewed the clinical record with inspectors and confirmed the belt should have been applied. He said he would speak with the nursing supervisor about it.
Four days later, nothing had changed.
On March 20, inspectors observed Resident #39 leaning forward in the wheelchair, pushing along the hallway using both feet, without the belt. LPN #6 was there. She acknowledged the resident needed it and said the nursing assistant must have forgotten again. She applied it after the surveyor said something.
The physician had ordered the belt on March 17. An occupational therapist had conducted an in-service with nursing staff on March 12, five days before the order was even written, specifically covering how to apply and use it. A physical therapist told inspectors that without the belt, Resident #39's positioning in the wheelchair would not be optimal and the resident would face a higher risk of falls.
The pattern here is not complicated. A resident slides forward in a wheelchair. A physician orders a belt to prevent that. Staff are trained on the belt before the order is even placed. The order goes in. The belt is not applied. An inspector finds it missing. A nurse applies it. The director says he will address it. Four days pass. The belt is missing again. Another nurse applies it after another inspector points it out.
When inspectors asked for the facility's policy on wheelchair equipment and pelvic positioning belts, the facility could not provide one.
The facility did have a policy on physician's orders, dated July 2023, directing that orders be documented and entered into the clinical record to ensure residents receive prompt and accurate treatment. It had a policy on nursing procedures directing that physical therapy services be provided in accordance with residents' needs. Neither policy appeared to have closed the gap between what was ordered for Resident #39 and what nursing staff actually did on any given shift.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's assessment of what had occurred so far. The physical therapist's own words describe what remained possible: a resident who already tends to slide forward, in a wheelchair, without the device ordered specifically to keep that from happening, at higher risk for a fall.
Resident #39 was not described in the inspection record as having fallen. The belt was applied each time an inspector asked about it. What the record shows is a resident who needed a piece of equipment, had it ordered by a physician, had nursing staff trained on it, and still went without it on at least two separate occasions across four days, each time until someone from outside the facility noticed.
The nursing assistants said they forgot. The nurses said the nursing assistants must have forgotten. The director said he would speak to the supervisor. The inspectors moved on.
Whether anyone spoke to the supervisor, and whether Resident #39's belt was applied the next morning without a surveyor present to ask about it, the inspection report does not say.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
NEW LONDON SUB-ACUTE AND NURSING in WATERFORD, CT was cited for violations during a health inspection on March 27, 2025.
Inspectors cited New London Sub-Acute and Nursing, located at 90 Clark Lane, following a survey completed March 27, 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.