Douglas Manor
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
days until the process was completed.
The Director of Social Services identified the facility failed to follow the requirements for filing a PASRR Level 2 when due.
Interview with the Administrator on [DATE] at 2:55 PM identified the facility failed to follow the requirements for filing a PASRR Level 2 for Resident #1 which caused Resident #1 to have to pay privately until Resident #1 was able to be accepted at a VA facility.
The facility Resident Rights policy identified residents have the right to a safe transfer or discharge through sufficient preparation by the nursing home.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Douglas Manor
103 North Road Windham, CT 06280
SUMMARY STATEMENT OF 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Douglas Manor
103 North Road Windham, CT 06280
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility policy Resident Rights identified the resident had the right to receive adequate and appropriate care.
Facility ID: