Douglas Manor: Care Delay Violation Found - CT
The inspection, conducted on August 18, 2025, was a complaint investigation. It produced one finding, but the finding came directly from the facility's own staff.
RN #1, interviewed that afternoon, laid out exactly what should have happened. Once a urine sample is ordered, the facility's own expectation is that it gets collected within twenty-four hours. If a resident's incontinence makes that impossible, the physician should be notified and asked whether the resident needs to be straight cathed, meaning a catheter inserted to obtain the sample directly. That is the protocol. RN #1 knew it.
None of it happened for Resident #1.
The physician was not called. The question of straight catheterization was never raised. The sample was not collected on time. RN #1 told inspectors that the failure to follow proper protocol caused a delay in treating Resident #1.
That acknowledgment came from inside the building. Inspectors did not have to argue the point.
The inspection report notes that Resident #1 was incontinent, which is precisely why the protocol exists. A resident who cannot produce a urine sample on demand is not a complication to be waited out. The nurse's own account made clear that incontinence was a known factor, that straight catheterization was a recognized option, and that the option was not pursued.
The facility's own resident rights policy, reviewed by inspectors, states that residents have the right to receive adequate and appropriate care. The inspection cites that policy directly in connection with what happened to Resident #1.
CMS rated the harm as minimal harm or potential for actual harm, with few residents affected. That is the lower end of the agency's harm scale. It does not mean nothing went wrong. It means inspectors found no documented evidence of serious physical injury to Resident #1 as a result of the delay. What it does not answer is what Resident #1 was being tested for, how long the delay lasted beyond the twenty-four-hour window, or what the physician ultimately found when treatment finally proceeded.
The inspection report does not say.
What it does say is that a nurse at Douglas Manor sat across from a federal inspector and described, in plain terms, a system that failed to work. The twenty-four-hour window existed. The notification requirement existed. The catheterization option existed. The resident's incontinence was not a surprise. And still, none of the available steps were taken.
Complaint investigations at nursing homes are typically triggered by someone, a resident, a family member, a staff member, contacting a state or federal agency with a concern. The report does not identify who filed the complaint or what they reported. It documents only what inspectors found when they arrived.
Douglas Manor is a nursing facility in Windham, Connecticut. The inspection covered one deficiency. The resident affected was one person. But the nurse's own account described a gap between what the facility's protocol required and what actually happened to a resident who depended on staff to navigate a basic medical step she could not manage on her own.
Resident #1 needed a urine sample collected. She was incontinent. There was a procedure for exactly that situation. The clock ran past twenty-four hours. The doctor was not called. The question was never asked.
By the time RN #1 explained all of this to an inspector on a Monday afternoon in August, the delay had already happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Douglas Manor from 2025-08-18 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.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 23, 2026 · Our methodology
DOUGLAS MANOR in WINDHAM, CT was cited for violations during a health inspection on August 18, 2025.
The inspection, conducted on August 18, 2025, was a complaint investigation.
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.