New London Sub-Acute: Resident Assault Unreported - CT

The incident happened on the evening of November 23, 2024, at New London Sub-Acute and Nursing, a facility on Clark Lane in Waterford. A resident identified in inspection records as Resident #84, who had a documented history of unprovoked aggression toward others, was pushing a cart down the hallway. Another resident, Resident #42, stepped in front of him to stop the cart from moving.

Resident #84 slapped Resident #42 open-handed on the right side of the face.

Then Resident #42 pushed Resident #84 into the wall.

LPN #14, who was assigned to the 3:00 PM to 11:00 PM shift that evening, saw both. She separated the two residents and called the nursing supervisor. What happened next is where the record begins to fracture.

The facility's own incident summary, completed three days after the altercation, described only one direction of violence. Resident #84 had slapped Resident #42. The document noted that LPN #14 had observed the altercation but was unable to respond quickly enough to intervene. It said nothing about Resident #42 pushing Resident #84 into the wall. Neither did the nurses note entered at 7:09 PM the same evening. Neither did any written statement collected in the days that followed.

When inspectors interviewed LPN #14 on March 24, 2025, four months after the incident, she described both strikes clearly. Resident #84 slapped Resident #42 on the side of the face. Resident #42 pushed Resident #84 into the wall. She had intervened immediately and notified the nursing supervisor.

The Director of Nursing Services was also interviewed that same afternoon. He confirmed the basic sequence: Resident #84 had been pushing something in the hall, Resident #42 tried to stop him, Resident #84 slapped Resident #42 in the face. Then the inspector asked about the second part.

The DNS said he had not been aware that Resident #42 had also pushed Resident #84. That detail, he acknowledged, had not been reported to him and had not appeared in any written documentation. He said it should have been reported at the time.

The nursing supervisor who had been on duty that night, RN #3, could not be reached for an interview.

Resident #84's care plan, last updated in October 2024, identified a history of inappropriate and disruptive behavioral symptoms, including unprovoked aggression toward others. The plan called for staff to anticipate his needs and intervene when necessary to protect the rights of other residents. A monitoring sheet from the evening of November 23 placed Resident #84 in the hallway between 6:15 PM and 6:30 PM, the window during which the assault occurred.

In the immediate aftermath, the facility placed both residents on one-to-one supervision. A nursing assessment found both residents at their baselines. No physical injuries were documented for Resident #42. Resident #84's physician was notified, as were the DNS and police. His prescribed Trazodone, an antidepressant, was increased from 25 milligrams daily to 50. Two days after the incident, on November 25, Resident #84 was transported to a psychiatric facility for evaluation and treatment.

Those were the steps taken for the resident who had thrown the first punch. The record contains nothing about what steps, if any, were taken in response to the fact that Resident #42 had shoved another resident into a wall.

That asymmetry is at the center of what federal inspectors cited. The facility's own abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy specified that willful means the individual acted deliberately, not that they intended to cause harm. By that definition, a resident deliberately pushing another resident into a wall fits. It was never documented as such. It was never reported up the chain. It did not appear in any written statement collected in the days following the incident. The DNS learned about it from a federal inspector, not from his own staff.

CMS cited the facility for failing to protect residents from abuse and classified the violation as causing actual harm to a small number of residents.

What the inspection report cannot answer is what Resident #84 experienced in the moment he was shoved into the wall, or in the days that followed before he was transferred to a psychiatric facility. The record notes he was assessed as being at baseline. It does not describe what baseline looked like for a man with a documented history of behavioral symptoms severe enough to require a care plan intervention, who had just been involved in a physical altercation in a hallway, whose medication was increased, and who was transferred out of the facility two days later.

The report also cannot answer why the second strike disappeared from every document the facility produced. LPN #14 remembered it clearly four months later. She told inspectors she had separated both residents and notified the supervisor. The supervisor, RN #3, was the person who would have received that notification. RN #3 was not available to be interviewed.

What the record does answer is this: a nurse watched two people assault each other, reported to her supervisor, and only one of those assaults made it into any written account. The other one stayed out of the paperwork until a federal inspector sat down with the nurse and asked her what she saw.

The DNS, when told what LPN #14 had described, said it should have been reported at the time.

It was not.

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

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