ElderGrade

Inspection citations at Douglas Manor

57 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 2 0
2025 25 1
2024 3 0
2023 21 0
2020 6 0
D April 8, 2026 Tag F0585 Complaint investigation Corrected May 2026

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D April 8, 2026 Tag F0550 Complaint investigation Corrected May 2026

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

D October 15, 2025 Tag F0658 Complaint investigation Corrected Nov 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

G October 15, 2025 Tag F0689 Complaint investigation Corrected Nov 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D August 18, 2025 Tag F0684 Complaint investigation Corrected Sep 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D August 18, 2025 Tag F0655 Complaint investigation Corrected Sep 2025

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D August 18, 2025 Tag F0645 Complaint investigation Corrected Sep 2025

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

B April 22, 2025 Tag F0568 Corrected Jun 2025

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

No actual harm, minimal potential

C April 22, 2025 Tag F0570 Corrected Jun 2025

Resident Rights Deficiencies

Assure the security of all personal funds of residents deposited with the facility.

No actual harm, minimal potential

D April 22, 2025 Tag F0880 Corrected Jun 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0791 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0695 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0689 Corrected Jun 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0684 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0610 Complaint investigation Corrected Jun 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0609 Complaint investigation Corrected Jun 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0578 Corrected Jun 2025

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0561 Corrected Jun 2025

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

E April 22, 2025 Tag F0940 Corrected Jun 2025

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

No actual harm, potential for more than minimal harm

E April 22, 2025 Tag F0761 Corrected Jun 2025

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

E April 22, 2025 Tag F0745 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

No actual harm, potential for more than minimal harm

E April 22, 2025 Tag F0657 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

E April 22, 2025 Tag F0567 Corrected Jun 2025

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

No actual harm, potential for more than minimal harm

E April 22, 2025 Tag F0565 Corrected Jun 2025

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

E April 22, 2025 Tag F0553 Corrected Jun 2025

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

No actual harm, potential for more than minimal harm

D April 7, 2025 Tag F0656 Complaint investigation Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D April 7, 2025 Tag F0609 Complaint investigation Corrected May 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D December 6, 2024 Tag F0689 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D July 30, 2024 Tag F0689 Complaint investigation Corrected Sep 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D July 30, 2024 Tag F0684 Complaint investigation Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

B March 13, 2023 Tag F0641 Corrected Apr 2023

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, minimal potential

D March 13, 2023 Tag F0888 Corrected Apr 2023

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0883 Corrected Apr 2023

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0697 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0692 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0686 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0684 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0677 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0658 Corrected Apr 2023

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D March 13, 2023 Tag F0657 Corrected Apr 2023

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.