Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New London Specialty Care during CMS and state inspections, most recent first.
Failure to Use Gait Belts During Resident Transfers: A CNA transferred one resident at high fall risk without a gait belt and, during the transfer, the resident’s O2 tubing became tangled and the resident fell, sustaining a displaced distal humerus fracture that required hospital transfer and surgical consultation. In a separate observation, another resident who required transfer assistance was moved from bed to wheelchair without a gait belt, despite the care plan directing gait belt use and staff confirming the belt should have been used.
A resident with dementia, diabetes with neuropathy, and moderate cognitive impairment fell and was later found to have a pelvic fracture. Facility notes were entered late and gave conflicting accounts about whether the PCP, family, and manager were notified. Interviews and provider records showed the NP did not receive timely notice of the fall, and staff stated the RN did not call the family or manager on call after the incident.
Failure to protect a resident from resident-to-resident aggression: one resident with moderate cognitive impairment threw a package of wipes at his roommate after becoming annoyed by singing, striking the roommate in the chest. The roommate, who had legal blindness and intact cognition, reported chest pain for 2 days and received Tylenol with relief; no visible injury was noted on assessment.
A CNA who had previously worked in dietary lacked documented orientation and competency verification after changing roles, yet worked independently with residents. A resident with a care plan requiring a 2-person transfer with a FWW and gait belt fell during a transfer performed without the gait belt, resulting in a fracture that required surgical repair. Interviews and record review showed the facility could not locate the CNA’s training records, competency checklist, or CNA start date, and the resident’s updated transfer instructions had not been signed by the CNA in the communication book.
Room meal trays were not maintained at a palatable and safe temperature. Residents reported that breakfast trays were late and food was often lukewarm or cold, and one resident said she frequently had to ask for her food to be warmed. During a breakfast tray observation, hot items were measured below the required temp and milk was above the cold holding limit. Dietary staff said trays often sat 10 to 15 minutes before CNAs delivered them.
A resident with dementia, weakness, and poor coordination was observed being pushed in a wheelchair with his feet off the foot pedals and sliding across the floor. The facility also failed to supervise the resident safely while he was attached to an EZ stand for toileting; he was later found on the floor in the shower room with the sling still attached. Staff interviews showed inconsistent understanding about leaving a resident alone with the device and about proper wheelchair foot placement.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to use a gait belt during transfers for 2 residents who were at risk for falls. Resident #6 had a BIMS score of 15 out of 15, diagnoses including acute and chronic respiratory failure with hypoxemia, diabetes, congestive heart failure, and morbid obesity, and required substantial to maximal staff assistance for transfers and repositioning. Her care plan directed that she be assisted by 2 staff using a four-wheeled walker and gait belt. After a fall on the way to the bathroom, she was found lying on her left side in the bathroom doorway, reported that she lost her balance, hit her head and left elbow, and had severe left elbow pain with inability to move the left arm without pain. The incident resulted in a hospital transfer and a diagnosis of a highly comminuted and displaced distal left humerus fracture requiring orthopedic consultation and surgical intervention. The record and interviews showed that the resident’s transfer assistance level had been changed to 2-person assist with gait belt and walker, and that this change was documented in the facility communication book. However, the CNA who assisted the resident on the night of the fall did not review the communication book, did not have her gait belt with her, and transferred the resident alone without a gait belt. During the transfer, the resident’s oxygen tubing became tangled, and when the CNA pulled on the tubing to free it, the resident fell backward onto the floor. Staff interviews confirmed that the CNA did not use a gait belt and that staff were expected to follow the resident’s care plan and use gait belts for transfers. The facility also observed a separate transfer of Resident #5, who had a BIMS score of 13 out of 15, diagnoses including vascular dementia, peripheral vascular disease, diabetes, and weakness, and required substantial staff assistance for transfers. Her care plan directed transfer assistance with a gait belt, front wheeled walker, and contact guard assist. During observation, a CNA assisted the resident from bed to wheelchair by supporting her under the arms and without a gait belt. The CNA stated she used gait belts kept in residents’ rooms but did not know whether one was in this resident’s room. The interim DON and MDS nurse stated the CNA should have used a gait belt as directed. The facility policy required use of appropriate lifting and movement techniques and training in manual transfer belts.
Delayed provider notification after resident fall
Penalty
Summary
The facility failed to notify the primary care provider in a timely manner after a resident’s fall. Resident #7 had diagnoses including dementia, diabetes with neuropathy, and acute osteomyelitis of the left ankle, and his cognitive testing showed moderate impairment. He was also identified in the care plan as being at risk for falls. After the fall, the resident was later found to have a nondisplaced fracture of the left superior pubis ramus and was transferred to the hospital for evaluation. Facility documentation showed conflicting and delayed charting about the fall and the notifications made. One late-entry nurse note stated the resident had fallen at 8:00 p.m., that family, the PCP, and the facility manager had been notified, and that the PCP later ordered the resident sent out because he was in extreme pain and could not move his right leg. Another incident note stated the resident was observed on the floor, assisted to a recliner, assessed, and monitored with neuro checks, and that the provider and the resident’s son were notified only after the resident began complaining of pain and was sent to the ED. The electronic record showed these notes were created days to weeks later. Staff interviews and provider records did not support timely notification of the PCP at the time of the fall. The LPN stated the resident fell during the evening shift and that the RN on duty reported the fall to her later; she believed the resident should have already been sent out for evaluation. The RN stated she initially messaged the NP after the resident became uncomfortable and later called again when the night nurse arrived, but she did not call the family or manager on call because she was not aware she was supposed to. The contracted provider network reported no documentation of a call about the fall, and the NP stated the only message he received was at 10:28 p.m., when he directed staff to send the resident to the hospital due to pain and probable injuries. The former DON and interim DON both stated staff were required to notify the provider, manager on call, and family after a fall, and the former DON stated she had not been notified until the next morning.
Failure to Protect Resident from Resident-to-Resident Aggression
Penalty
Summary
The facility failed to protect a resident from a resident-to-resident incident when one resident threw a package of disposable wipes at his roommate, striking the roommate in the chest. The incident was self-reported by the facility and documented as involving contact with the roommate, with no visible injuries noted on assessment. The roommate later reported being upset and angry about the event and stated he did not know why it happened. The resident who threw the wipes had a history of cerebrovascular accident with hemiplegia and depression, and a BIMS score of 10 indicated moderate cognitive impairment. He was dependent on staff for all ADLs except eating and oral hygiene. The resident who was struck had diabetes, legal blindness, mood disorder, and PTSD, with intact cognition and limited staff supervision or touch assistance needed for ambulation due to severely impaired vision. During interviews, the resident who threw the wipes stated he did so because he did not like the roommate singing and had not asked him to stop. The struck resident reported the impact caused chest pain for 2 days and that he was caught off guard because he could not see the action due to his blindness. Nursing documentation noted no visible injury, but pain was recorded and acetaminophen was administered with relief.
CNA Lacked Documented Orientation and Competency Before Independent Resident Care
Penalty
Summary
The facility failed to ensure that a staff member who changed positions from dietary employee to CNA completed orientation and demonstrated skill competencies before working independently with residents. Review of the personnel file for the CNA showed an initial hire date as a dietary employee, a later CNA certification inquiry indicating active CNA status, and a CNA job description signed by the staff member, but no documentation showing the start date as a CNA, completion of CNA orientation, or verification of CNA competency. The facility’s orientation policy required newly hired nurse aides to attend orientation within their first 5 days of employment, and the competency policy required nursing assistants to participate in a competency-based training program and demonstrate specific competencies needed to care for residents. The deficiency was identified after a self-reported incident in which Resident #6 fell during a transfer performed by the CNA without a gait belt. Resident #6’s care plan required a two-person assist and use of a four-wheeled walker and gait belt for transfers. The fall resulted in a fracture requiring surgical repair. Interviews with the Business Office Manager/HR Director and the interim DON confirmed the facility could not locate documentation of the CNA’s training, competency checklist, or start date as a CNA, and the interim DON stated the resident’s care plan change to a two-staff transfer with gait belt and walker had been documented in the communication book, but the CNA had not signed it when she worked on the date of the incident.
Room Trays Served at Improper Temperatures
Penalty
Summary
The facility failed to maintain room meal trays at a palatable and safe temperature for one observed meal service. Resident council meeting questions from January 2026 showed residents reported that food was not always up to temperature, breakfast trays were late, and hamburgers and waffles were usually lukewarm. During an interview, one resident stated she ate breakfast in bed and that the food was cold all the time, and she said the facility needed food warmers. During an observation of breakfast room tray delivery, trays were delivered down A hall first, and a test tray was checked with temperatures of 97.5 degrees F for French toast, 102.6 degrees F for sausage, and 47.5 degrees F for milk. The resident later stated she had only taken a bite of her sausage because it was less than warm and said she asked the facility to warm up her food 75% of the time. Dietary staff stated room trays were prepared by dietary and delivered by CNAs, and that trays sat about 10 minutes before CNAs delivered them, with some trays sitting 15 minutes before staff were ready to pass them. The Dietary Manager stated the facility tried to get staff to pass trays on time and identified the required holding temperatures as cold items not over 40 degrees F and hot items at 135 degrees F or above.
Unsafe wheelchair transport and unsupervised use of mechanical sit-to-stand device
Penalty
Summary
The facility failed to ensure Resident #27 was transported in a wheelchair with his feet positioned on the foot pedals. During observation, the resident was propelled from the dining room and then down Hallway B with both feet outside the foot pedals, sliding across the floor while the CNA continued to push the wheelchair. Staff later confirmed that residents' feet should be on the wheelchair foot pedals when being pushed, and the CNA stated Resident #27 did not like to place his feet on the pedals and had to be reminded multiple times. The facility also failed to ensure Resident #27 was safely supervised while using a mechanical sit-to-stand device for toileting. Resident #27 had diagnoses including non-Alzheimer's dementia, generalized muscle weakness, and unspecified lack of coordination, and the care plan directed that he use a hoyer for most transfers and a stand-eze with assist of 2 for toileting transfers. The care plan also directed staff not to leave him alone in the bathroom and to provide cues, re-orient, and supervise as needed because of impaired cognition and dementia. After the unwitnessed fall, staff documented that Resident #27 was found on the floor in a sitting position in the shower room with the EZ stand sling still under his arms and attached to the device. Staff interviews showed differing understandings about whether a resident could be left alone while attached to the mechanical sit-to-stand, with some staff stating they had been trained to leave the resident alone if the brakes were locked and a call light was provided, while others stated they would not leave him alone because it was not safe. The DON also stated residents could be left attached to the device in the bathroom with the brakes locked and a call light.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New London
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Savannah Heights | 7.1 mi | ★★★★★ | 1 | 0 |
| Woodland Health And Rehabilitation | 8.2 mi | ★★★★★ | 6 | 0 |
| Park Place | 8.6 mi | ★★★★★ | 2 | 0 |
| Azria Health Prairie Ridge | 13.6 mi | ★★★★★ | 19 | 0 |
| Sunrise Terrace Nursing & Rehabilitation Center | 14.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.