New London Sub-Acute: Repositioning Failures Found - CT
The aide, identified in inspection records as NA #10, began her shift at 7:00 AM. When surveyors observed the resident, identified as Resident #4, at 11:40 AM, the person was still lying on their back with the head of the bed slightly elevated, exactly as they had been hours earlier. Nobody had turned them.
When inspectors spoke with NA #10 at 11:50 AM, she said she had not turned or repositioned Resident #4 since her shift began. She explained that she relied on resident-specific tasks that appeared in the facility's electronic charting system, and she would complete tasks when the system prompted her. Resident #4 did not have a directive set up in the system that would have flagged the need for repositioning. She said she was not aware the resident needed to be turned every two hours.
Only after surveyors raised the issue was Resident #4 finally repositioned. At noon, the resident was observed lying on their right side, facing the window.
It was not just one aide who had missed the task that morning. LPN #8, who had also been on shift since 7:00 AM, told inspectors during a 2:30 PM interview that she had not attempted to turn or reposition Resident #4 during her shift either. She acknowledged the physician order requiring repositioning every two hours existed. She mentioned that Resident #4 sometimes refused repositioning, but when inspectors pressed her, she could not produce a refusal care plan or any progress note documenting a single refusal. Nothing had been written down.
A second resident, Resident #26, was also left in the same position after incontinent care that morning. At 10:30 AM, inspectors observed two nurse aides, NA #10 and NA #11, completing incontinent care on Resident #26. When they finished, the resident remained lying on their back, exactly as before.
A social worker, identified as SW #2, entered Resident #4's room and left without repositioning the resident as well.
The Director of Nursing Services, interviewed at 3:00 PM on March 20, said NA #10 should have checked her care card to determine what Resident #4 needed and would be re-educated. The DNS confirmed that Resident #4 should have been turned and repositioned every two hours, and that any refusals needed to be reported to a nurse or supervisor so interventions could be put in place and documentation completed.
The facility's own turning and repositioning policy stated that position changes were to happen every two to three hours, and that for residents dependent on staff for mobility, staff were to check for toileting needs during each repositioning as well.
What the inspection uncovered was a gap between what the policy said, what the physician ordered, and what actually happened in the rooms. The electronic charting system was supposed to prompt staff to act. For Resident #4, no prompt had been set up. The aide responsible for the resident's care had no alert telling her to turn the person, and so she didn't. The licensed nurse on the same shift knew the order existed and still did not act on it.
Pressure injuries, the clinical term for bedsores, develop when sustained pressure cuts off circulation to skin and underlying tissue. Residents who cannot reposition themselves are dependent entirely on staff to relieve that pressure at regular intervals. A missed two-hour window does not always cause visible harm immediately. Five hours is a different matter.
Resident #4 spent the morning of March 20 on their back, facing the ceiling, until a surveyor's question changed that.
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 30, 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 aide, identified in inspection records as NA #10, began her shift at 7:00 AM.
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.