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Douglas Manor: Care Plan Violations Found - CT

Healthcare Facility
Douglas Manor
Windham, CT  ·  1/5 stars

The resident, identified only as Resident #1 in inspection records, was admitted to the North Road facility on May 28. Staff developed a baseline care plan that same day outlining the person's complex medical needs, including a colostomy, bladder incontinence, and requirements for maximum assistance with dressing and complete dependence for toileting, transfers and walking.

The plan detailed specific interventions: toilet the resident every two hours, provide incontinence care, apply barrier protection, obtain lab work as ordered, administer medications, monitor behaviors, arrange psychiatric consultations as needed, and assist with daily living activities.

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But facility records show no meeting occurred with the resident or family to discuss this care plan until July 28 — exactly two months after admission.

The Director of Social Services told inspectors on August 18 that she "thought a meeting was held" but couldn't be certain because she hadn't documented any such meeting in the clinical record. When pressed, she checked with the therapy department, which attends all care plan meetings at Douglas Manor.

The therapy department had no record of any meeting taking place.

A Care Plan Meeting Invitation form documented that facility staff finally met with the resident and family members on July 28 "and addressed concerns Resident #1 and his/her family had." The inspection report provides no details about what those concerns were or how long the family had been waiting for answers.

During those two months, the resident's medical complexity became clearer through ongoing assessments. The admission Minimum Data Set evaluation revealed significant cognitive and physical limitations: some memory deficits, moderate assistance needed for personal hygiene and bed mobility, maximum assistance required for dressing, and complete dependence for showering, transfers and walking.

The person remained "always incontinent of bladder" and required management of their colostomy, according to the assessment.

Federal regulations require nursing homes to involve residents and their families in care planning from the moment of admission. The facility's own policies acknowledge these requirements. Douglas Manor's Resident Rights policy states that residents have "the right to participate in their own care-planning and treatment." The facility's Care Plan policy similarly identifies that residents have "the right to participate in the development and implementation of his/her plan of care."

Yet for eight weeks, this resident and their family had no formal opportunity to discuss treatment decisions, raise concerns, or understand the interventions being provided daily.

The violation represents what inspectors classified as "minimal harm or potential for actual harm" affecting "few" residents. But the case illustrates a breakdown in basic communication requirements designed to keep families informed about their loved one's medical care.

Nursing home care plans serve as roadmaps for daily treatment, outlining everything from medication schedules to assistance needs for basic activities. When families don't receive these documents promptly, they cannot advocate effectively for their loved ones or understand why certain treatments are being provided.

The inspection occurred as part of a complaint investigation on August 18. Douglas Manor operates as a skilled nursing facility on North Road in Windham, serving residents with complex medical needs requiring around-the-clock care.

Federal law mandates that nursing homes create comprehensive care plans within seven days of admission, but baseline plans must be shared with residents and families within 48 hours to ensure continuity of care and communication with staff.

The resident in question required extensive daily assistance across multiple areas of functioning, from basic hygiene to mobility support. Their psychiatric conditions — depression and bipolar disorder — added another layer of complexity requiring behavioral monitoring and potential psychiatric consultations.

For two months, the family navigated this complex care situation without formal documentation of their loved one's treatment plan or an opportunity to discuss concerns with facility staff in a structured care planning meeting.

The July 28 meeting finally provided that opportunity, but only after the facility had missed the federal deadline by 56 days.

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


Editorial Standards

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

Quick Answer

DOUGLAS MANOR in WINDHAM, CT was cited for violations during a health inspection on August 18, 2025.

The resident, identified only as Resident #1 in inspection records, was admitted to the North Road facility on May 28.

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.

Frequently Asked Questions

What happened at DOUGLAS MANOR?
The resident, identified only as Resident #1 in inspection records, was admitted to the North Road facility on May 28.
How serious are these violations?
Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
What should families do?
Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in WINDHAM, CT, (5) Report any new concerns directly to state authorities.
Where can I see the full inspection report?
The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from DOUGLAS MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 075258.
Has this facility had violations before?
To check DOUGLAS MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.


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