A list of the most recent deficiencies for Haven of Douglas. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2023-01-26 | 2023-03-20 | N |
| Post nurse staffing information every day. | Health | 2023-01-26 | 2023-03-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-26 | 2023-03-20 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-26 | 2023-03-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-26 | 2023-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-26 | 2023-03-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-26 | 2023-03-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-26 | 2023-03-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-26 | 2023-03-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-05 | 2021-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-05 | 2021-12-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-05 | 2021-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-05 | 2021-12-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-05 | 2021-12-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-04 | 2021-11-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-04 | 2021-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-04 | 2021-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-04 | 2021-11-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-04 | 2021-11-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-28 | 2019-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-28 | 2019-07-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-28 | 2019-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-28 | 2019-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-27 | 2019-07-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-27 | 2019-07-15 | N |
