A list of the most recent deficiencies for Douglas Manor. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-13 | 2023-04-24 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-03-13 | 2023-04-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-13 | 2023-04-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-13 | 2023-04-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-13 | 2023-04-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-03-13 | 2023-04-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-13 | 2023-04-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-13 | 2023-04-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-13 | 2023-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-13 | 2023-04-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-13 | 2023-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-13 | 2023-04-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-13 | 2023-04-24 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-13 | 2023-04-24 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-03-13 | 2023-04-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-13 | 2023-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-04-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-13 | 2023-04-24 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-13 | 2023-04-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-13 | 2023-04-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-13 | 2023-04-24 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-06 | 2023-04-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-06 | 2023-04-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-03-06 | 2023-04-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-06 | 2023-04-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-19 | 2022-03-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-19 | 2022-03-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-05 | 2020-03-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-05 | 2020-03-18 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-05 | 2020-03-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-05 | 2020-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-05 | 2020-03-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-05 | 2020-03-18 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-02-04 | 2020-02-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-06 | 2019-01-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-06 | 2019-01-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-12-06 | 2019-01-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-06 | 2019-01-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-06 | 2019-01-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-06 | 2019-01-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-06 | 2019-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-06 | 2019-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-06 | 2019-01-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-06 | 2019-01-09 | N |
