New London Sub-Acute: Medication Safety Failures - CT
When inspectors returned on August 21, the medications were still being administered late. The supply was still running out before refills arrived. The prescribing nurse practitioner was still not being told when doses were missed. The plan of correction the facility had submitted after its June 30 inspection, with a promised fix date of July 31, had not been carried out.
The facility was cited for immediate jeopardy.
That designation, the most serious finding federal inspectors can make, means the failure created a situation likely to cause serious injury, harm, or death. At New London Sub-Acute, it applied specifically to pharmacy services and the administration of medications free of significant errors.
This was not the first time inspectors had reached that conclusion about this facility. It was not even the second.
The March 27, 2025 annual survey found medication errors. The June 30, 2025 complaint survey found significant medication errors, a more serious finding, and inspectors documented that nurses were administering medications late and not notifying supervisors or prescribers when they did. The facility submitted a plan of correction committing to staff education, audits, and a quality assurance process. The correction date was July 31.
By August 20, the day before the third inspection, medications were still being administered late.
The administrator, the director of nursing, and a corporate regional nurse were interviewed together on August 21 at 1:28 in the afternoon. None of them could describe a functioning process for ensuring medications were refilled before supplies ran out. None could describe a working system for ensuring timely administration. None could describe how the facility was making sure prescribers were being told when their orders weren't being followed.
The interview, as the inspection report put it, "failed to identify the facility was able to sustain compliance."
What the report describes is not a single bad week or a staffing gap that caught a facility off guard. It is a pattern documented across three separate inspections spanning five months, with the same failures appearing each time: medications not given when ordered, medications not on hand to give, providers not informed when their patients went without. The residents affected were described as few in number. The harm level was assessed as minimal or potential for actual harm. But the medications at issue, anxiety medications and narcotic pain medications, are not optional. They are prescribed because something is wrong that requires them.
A resident who goes without a scheduled narcotic pain medication does not simply experience mild discomfort until the next dose. A resident whose anxiety medication is not administered because the supply ran out and no one ordered a refill in time does not simply wait calmly. These are medications with clinical consequences when missed, which is precisely why the prescriber is supposed to be notified when a dose is skipped. At New London Sub-Acute, that notification was not happening.
The facility's own administrator job description, reviewed by inspectors, stated that the administrator was responsible for planning, organizing, developing, directing, controlling, and supervising the overall operations of the facility to ensure the highest degree of quality resident life. The inspection report cited that job description by name.
The implication was direct. Someone was responsible for making sure this didn't keep happening. The administrator's own job description said so. And yet here were the same violations, again, seven weeks after the facility had promised to correct them.
The corporate regional nurse was present for the August 21 interview. That detail matters. This was not a facility operating in isolation, unaware that outside eyes were watching. A regional nurse from the corporate level was on site. The facility had been through two prior surveys on the same issues. Everyone in that 1:28 PM interview knew what inspectors had found before, knew what the plan of correction had promised, and could not explain why the problems persisted.
The inspection also found that annual performance evaluations for staff had not been completed when due, that the clinical record was not complete and accurate, and that the APRN, the advanced practice registered nurse responsible for prescribing, had not been notified of medication omissions. These findings ran alongside the medication failures, not separate from them. A facility that isn't completing staff evaluations on schedule and isn't maintaining accurate clinical records is a facility where the infrastructure for catching and correcting problems has broken down.
The June 30 plan of correction had identified exactly the right interventions: educate staff, conduct audits, run a quality assurance process. Those are the standard tools. The facility knew what was needed. The correction date came and went.
There is a particular quality to a third citation for the same problem. The first time, it might be a gap in training or a temporary staffing disruption. The second time, with a formal plan of correction in place, it begins to look like a system that cannot hold what it promises. The third time, with immediate jeopardy declared and a corporate nurse in the room, it is something else. It is a facility that has been told, in writing, by federal regulators, what it must do, has agreed to do it, has set a date by which it would be done, and has not done it.
The residents whose anxiety medications went undelivered, whose narcotic pain medications were not given on time, did not know they were living inside a compliance timeline. They knew whether they were in pain. They knew whether they were frightened. They knew whether someone came when they were supposed to come.
At New London Sub-Acute and Nursing, on 90 Clark Lane in Waterford, the answer to that last question, documented now across three inspections, is that sometimes nobody came.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
NEW LONDON SUB-ACUTE AND NURSING in WATERFORD, CT was cited for violations during a health inspection on August 21, 2025.
When inspectors returned on August 21, the medications were still being administered late.
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.