DOUGLAS MANOR
Open-data reference.
DOUGLAS MANOR is a for profit - limited liability company facility in WINDHAM, CT with 90 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file.
103 NORTH ROAD, WINDHAM, CT 06280
Phone: 8604234636
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 075258
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 90
- Residents
- 85
- In Hospital
- No
- County
- Northeastern Ct
- Last Inspection
- Apr 22, 2025
Staffing Data
- RN Hours
- 0.58 (nat'l avg: 0.68)
- LPN Hours
- 0.98
- CNA Hours
- 1.97
- Total Nursing Hours
- 3.53 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 41.7%
- RN Turnover
- 11.1%
What the CMS Record Reveals About DOUGLAS MANOR
DOUGLAS MANOR operates 90 certified beds in WINDHAM, CT with approximately 85 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (4★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.53 total nursing hours per resident day (national average 3.89), with RN coverage at 0.58 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, DOUGLAS MANOR falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 41.7%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 21, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 21, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 29, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 29, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 29, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 28, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 28, 2025
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category: Administration Deficiencies
Corrected: Jun 28, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 28, 2025
Provide or obtain dental services for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 28, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 28, 2025
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 28, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 28, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 28, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 28, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 28, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jun 28, 2025
Assure the security of all personal funds of residents deposited with the facility.
Category: Resident Rights Deficiencies
Corrected: Jun 28, 2025
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Category: Resident Rights Deficiencies
Corrected: Jun 28, 2025
Honor the resident's right to manage his or her financial affairs.
Category: Resident Rights Deficiencies
Corrected: Jun 28, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Jun 28, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Jun 28, 2025
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category: Resident Rights Deficiencies
Corrected: Jun 28, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 19, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 19, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 23, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 10, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 10, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 24, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 24, 2023
Ensure staff are vaccinated for COVID-19
Category: Infection Control Deficiencies
Corrected: Apr 24, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Apr 24, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 24, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 24, 2023
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 24, 2023
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 24, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 24, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 24, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 24, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 24, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 24, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 24, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 24, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 24, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 24, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Apr 24, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Apr 24, 2023
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category: Resident Rights Deficiencies
Corrected: Apr 24, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Apr 24, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Mar 18, 2020
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 26.6% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.1% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.2% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 90.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 57.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 18.6% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 14.6% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 96.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 54.1% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 17.5% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 23.1% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for DOUGLAS MANOR?
What are the staffing levels at DOUGLAS MANOR?
How many beds does DOUGLAS MANOR have?
Does DOUGLAS MANOR have any deficiencies on record?
Has DOUGLAS MANOR received any fines or penalties?
Who owns DOUGLAS MANOR?
When was DOUGLAS MANOR last inspected?
What quality measures are tracked for DOUGLAS MANOR?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.