New London Sub-Acute: Drug Record Falsification - CT
The nurse told inspectors on August 19 that she "forgot to sign off the lorazepam as not administered" for a resident's noon dose on August 5. She acknowledged she should have checked clinical records before ending her shift and written a note explaining the medication was unavailable.
Resident #2 lived with dementia, behavioral disturbances, anxiety disorder, depression, and delusional disorder. A physician had ordered lorazepam oral concentrate for anxiety, agitation, and irritability — 0.5 mL by mouth three times daily starting August 5.
But the medication administration record for that first noon dose remained blank. No signature. No explanation.
The facility couldn't produce the required Controlled Drug Record disposition sheet for the lorazepam when inspectors requested it during their August 21 complaint investigation.
A second resident's controlled medication records also failed to match administration records, though specific details weren't documented in the inspection report.
The Director of Nursing told inspectors that controlled drug disposition sheets "should always match the resident's MAR for the same medication." She said she was unaware of the discrepancies between the records for both residents.
"Staff should always be ensuring their work is complete and accurate before leaving the facility," the director told inspectors.
Federal regulations require nursing homes to maintain accurate medication records, particularly for controlled substances like lorazepam. The drug belongs to a class of medications that can cause sedation, confusion, and increased fall risk in elderly patients with dementia.
Missing documentation makes it impossible to track whether residents received prescribed medications or if controlled substances were diverted. The facility's own policy, dated June 2023, requires that "documentation in the medical record will be complete and accurate."
LPN #1's admission that she forgot basic documentation requirements raises questions about medication management oversight at the 90 Clark Lane facility. She told inspectors she should have written a nurse's note if the medication was unavailable, but failed to do so.
The inspection found the violations caused minimal harm to residents, though the potential for actual harm existed. Proper medication administration and documentation protects vulnerable residents from both under-treatment and over-medication.
Lorazepam carries particular risks for dementia patients. The medication can increase confusion and fall risk, making accurate dosing and documentation critical for resident safety.
The facility's care plan for Resident #2 specifically directed staff to "monitor for side effects and effectiveness every shift" when administering psychotropic medications. Missing documentation undermines this monitoring requirement.
Federal inspectors classified the violations under tag F842, which covers medication administration requirements. The citation indicates systemic problems with controlled substance tracking that affected multiple residents.
The Director of Nursing's acknowledgment that she was unaware of the documentation problems suggests inadequate oversight of medication management practices. Nursing supervisors are responsible for ensuring staff complete required documentation before leaving their shifts.
New London Sub-Acute and Nursing must submit a plan of correction addressing how it will ensure accurate medication documentation going forward. The facility operates at 90 Clark Lane in Waterford, serving residents who require skilled nursing and rehabilitation services.
The August complaint investigation revealed documentation failures that could mask whether residents received prescribed controlled substances. Without accurate records, the facility cannot demonstrate proper medication management or identify potential diversion of controlled drugs.
LPN #1's forgotten signature represents more than paperwork oversight. It reflects a breakdown in the basic safeguards designed to protect vulnerable residents who depend on staff to manage their complex medication regimens safely and accurately.
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 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
NEW LONDON SUB-ACUTE AND NURSING in WATERFORD, CT was cited for violations during a health inspection on August 21, 2025.
The nurse told inspectors on August 19 that she "forgot to sign off the lorazepam as not administered" for a resident's noon dose on August 5.
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.