New London Sub-Acute: Medication Failures - CT
Resident #2 at New London Sub-Acute and Nursing was prescribed lorazepam three times daily in August after a psychiatric nurse practitioner noted the resident "could become angry with an explosive temper without provocation, was hostile with staff members of color and combative with care." The resident's memory was so poor they scored just three out of fifteen on a cognitive assessment and "could not recall anything for longer than a few minutes."
The psychiatric evaluation on August 5 recommended that when the resident became agitated, staff should "walk away and reapproach after a few minutes." A physician ordered lorazepam oral concentrate that same day to manage the anxiety, agitation and irritability.
But medication records show the resident never received the first doses. The lorazepam wasn't given at noon or 4 p.m. on August 5, the day it was prescribed. The resident missed the morning dose on August 6, the afternoon dose on August 7, and both morning and noon doses on August 8.
Nurses documented various reasons for the missed medications. Sometimes the drug was "unavailable." Other times the resident refused it or was sleeping. But nursing notes failed to show that supervisors or the prescribing physician were notified about any of the omissions, as facility policy required.
LPN #1 told inspectors on August 19 that although she failed to give the lorazepam on three separate days, "she was unaware she had to notify the nursing supervisor for all missed medication administrations and refusals so the nursing supervisor can notify the provider for possible alternative orders."
The Director of Nursing said she had no idea that Resident #2 and another resident had missed scheduled narcotic medications in July and August. She acknowledged that "the pharmacy and provider should have been contacted for all unavailable medications, medication refusals and missed administrations and this should be documented in the clinical record."
The medication failures weren't isolated incidents. Federal inspectors discovered that the facility's emergency stock of critical medications had been completely depleted since before June 17 and never refilled. The empty emergency supply included lorazepam oral concentrate, morphine sulfate oral solution, and hydrocodone combination tablets.
This meant that when regularly ordered medications weren't available from the pharmacy, nurses had no backup supply to ensure residents received prescribed pain relief or anti-anxiety medications. The facility's own policies required medications to be given within 60 minutes of the ordered time and mandated immediate reporting of medication errors to attending physicians.
Resident #2's case illustrated the human impact of these systemic failures. The resident had been admitted with diagnoses including bipolar disorder and mood disorder, requiring careful monitoring of psychotropic medications "every shift" for side effects and effectiveness. The psychiatric evaluation specifically noted that the resident's confusion meant they couldn't remember incidents of agitation, making consistent medication management crucial for both the resident's wellbeing and staff safety.
The facility's Medication Omission policy, dated July 2023, explicitly directed that nurses could only withhold medications using "professional judgement" and must immediately notify supervisors who would contact the prescribing physician. All omissions required documentation with "the date, specific time, and pertinent details" in nursing notes.
But the systematic breakdown in communication meant that when nurses encountered problems administering medications, the information never reached the people who could solve them. Physicians remained unaware that their orders weren't being followed. Supervisors couldn't intervene when emergency supplies ran low. And residents like #2 went without prescribed treatments for behavioral symptoms that put both them and staff at risk.
The inspection revealed that this wasn't a matter of individual nurse error but institutional failure. Multiple staff members were unaware of basic notification requirements. Emergency supplies sat empty for months without replacement. And the Director of Nursing had no systems in place to track whether residents were actually receiving their prescribed medications.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" affecting "some" residents. But for Resident #2, struggling with explosive anger and an inability to form new memories, the missed doses of anxiety medication represented a failure to provide the most basic element of nursing home care: ensuring residents receive the treatments their doctors prescribed.
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.
But medication records show the resident never received the first doses.
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.