Complaint Investigation

Douglas Manor

August 18, 2025 · Windham, CT · 103 North Road

Citations 3

CMS Rating 1/5

Beds 90

Provider ID 075258

Healthcare Facility

Douglas Manor

Windham, CT · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

DOUGLAS MANOR in WINDHAM, CT — inspection on August 18, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0645

Resident Assessment and Care Planning Deficiencies

privately until Resident #1 was able to be accepted at a VA facility.

The facility Resident Rights

075258 08/18/2025

Douglas Manor 103 North Road Windham, CT 06280

FF0655

Resident Assessment and Care Planning Deficiencies

Review of the clinical record from 5/28/25 when the baseline care plan was developed through 7/28/25 failed to reflect documentation a meeting was held with Resident #1 and the family to discuss Resident #1's care or a copy of the care plans were provided until the 7/28/25 meeting.

The Care Plan Meeting Invitation form identified the facility had a meeting with Resident #1 and family members on 7/28/25 and addressed concerns Resident #1 and his/her family had.

Interview with the Director of Social Services on 8/18/25 at 2:25 PM identified she thought a meeting was held; however, she could not be sure because she did not document in the clinical record that a meeting occurred.

The Director of Social Services checked further with the therapy department as they attended all care plan meetings, and the therapy department had no record of the meeting being held.

Review of the facility Resident Rights policy identified the resident had the right to participate in their own care-planning and treatment.

Review of the facility Care Plan policy identified the resident had the right to participate in the development and implementation of his/her plan of care.

075258 08/18/2025

Douglas Manor 103 North Road Windham, CT 06280

FF0684

Quality of Life and Care Deficiencies

Registered Nurse (RN) #1, on 8/18/25 at 2:18 PM identified the facility expectation to collect a urine

Resident #1's incontinence. RN #1 identified failure to follow proper protocol caused a delay in

to receive adequate and appropriate care.

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WINDHAM, CT, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DOUGLAS MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.