New London Sub-Acute: Medication Delays for Dementia Patients - CT
Inspectors from the Centers for Medicare and Medicaid Services visited New London Sub-Acute and Nursing on March 27, 2025, and found a pattern of late medication passes affecting multiple residents with severe cognitive impairment, including people being treated for hypertension with drugs that require consistent timing to work.
Resident 72, whose diagnoses included dementia, hypertension, and failure to thrive, had a physician's order requiring Hydralazine 100 mg three times a day. Hydralazine is a fast-acting blood pressure medication. A review of facility records showed it was administered at 2:42 PM, nearly three hours after the scheduled lunchtime pass. The facility's own policy requires medications to be given within 60 minutes of the designated time. This was nearly three times that window.
Resident 78, who had dementia, hypertension, and depressive episodes, was prescribed Trazodone 25 mg daily at noon. Trazodone, used here for depression, was given at 1:59 PM. That's 59 minutes past the outer boundary the facility set for itself.
A third resident received both Novolog insulin and Hydralazine at 2:41 PM, two hours and forty-one minutes late.
None of these residents could advocate for themselves. All three had severe cognitive impairment documented in their quarterly assessments.
When inspectors spoke with the facility's advanced practice registered nurse about the late medication pass on March 26, she acknowledged she was aware of the delays. Her characterization of what happened: the late medications were not significant medication errors.
That assessment sits uneasily against what the drugs are. Hydralazine works by relaxing blood vessel walls to bring down blood pressure. Insulin controls blood sugar. Both are medications where timing is not incidental. A delayed dose is not the same as a skipped dose, but for residents who cannot feel or report the effects of fluctuating blood pressure or blood sugar, the gap between what was ordered and what was given matters in ways that can't always be measured in a chart note.
The facility's own written policy, dated July 2023, states that medication errors and adverse drug reactions shall be immediately reported to the attending physician, documented in clinical records, and described in a Medication Error Report. There is no indication in the inspection report that any of these steps occurred before inspectors arrived.
The inspection identified the level of harm as minimal or potential for actual harm, and noted that some residents were affected. That language comes from a federal rating scale. What it means in practice is that inspectors found no documented injury tied directly to the delays, but could not rule out that harm occurred or might occur if the pattern continued.
New London Sub-Acute and Nursing sits on Clark Lane in Waterford, a short drive from the Connecticut shoreline. It serves residents in sub-acute and long-term care. The residents named in this inspection were among the most vulnerable people in the building, people whose dementia meant they could not track their own medication schedules, remind a nurse that a pill was late, or describe a headache that might signal a spike in blood pressure.
The APRN's dismissal of the delays as insignificant was the detail that inspectors chose to include in the record. It suggests not a single bad afternoon, but a culture in which a two-hour-and-forty-two-minute gap between a physician's order and a resident's medication is considered, by a licensed clinician, to be unremarkable.
For Resident 72, who had dementia and failure to thrive, noon came and went. So did one o'clock. The medication arrived when it arrived.
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: November 4, 2026 · Our methodology
NEW LONDON SUB-ACUTE AND NURSING in WATERFORD, CT was cited for violations during a health inspection on March 27, 2025.
Resident 72, whose diagnoses included dementia, hypertension, and failure to thrive, had a physician's order requiring Hydralazine 100 mg three times a day.
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.