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Douglas Manor: Care Plan Withheld for Two Months - CT
The requirement to share that plan within forty-eight hours of admission isn't a formality....
Latest reports, citations, and penalties from CMS data
The requirement to share that plan within forty-eight hours of admission isn't a formality....
A standardized cognitive assessment gave her a score of 2 out of 15, placing her in the range of severe cognitive impairment....
The resident, identified in the report only as Resident 2, had two pinpoint openings in the sacral area, a wound site that demands careful infection control....
The resident was cognitively intact and required assistance with personal care, according to a June 2025 assessment of his abilities and care needs....
The facility's own nursing director said so out loud during an inspection on August 19, 2025....
She said a staff member at the nursing home told her the medication had not arrived yet....
Three months later, a federal inspector walked through all three units of the facility and found conditions that supported the complaint....
The wound care procedure involving Resident 18 unraveled in stages....
The resident, identified in inspection records only as Resident D, was already among the facility's most vulnerable....
The Director of Nursing later confirmed this directly to inspectors....
The resident, identified in inspection records only as Resident B, was admitted from her home and was already receiving hospice services when she arrived....
That gap, uncovered during a complaint inspection completed August 20, sits at the center of a deficiency citation against the facility....
The inspection identified failures in how the facility monitored, documented, and reported signs of infection and complications to physicians....
The resident, identified in inspection records only as Resident O, carries diagnoses of osteomyelitis, a serious bone infection, and schizophrenia....
A witness, another resident, walked to the social services office the following morning and reported what he had seen....
An inspector noticed the outdated posting at 9:40 that morning....
Federal inspectors visited the Pasadena facility on August 19, 2025, and documented the finding as part of a complaint investigation....
The resident, identified in inspection records only as Resident E, had a physician's order written at 1:16 p.m....
That was August 19, 2025, the day surveyors arrived for a complaint inspection....
When he asked a therapist why, he was told they didn't have enough staff....