Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Douglas during CMS and state inspections, most recent first.
Failure to prevent resident elopement: A resident with Alzheimer’s dementia, significant cognitive impairment, and a documented history of wandering and exit-seeking left the facility and was found several blocks away after a community member reported seeing her walking down the street. Staff had noted the resident in the dining room shortly before the incident, and the RN stated the resident said she was going for a walk and would return later. The DON stated the door alarm was functioning but too quiet for staff to hear.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Unsafe food storage and expired items were found during kitchen observations. Staff identified an undated meal box with bologna sandwiches, opened food items without proper date marking, expired marinara sauce and cooked ham in the freezer, and multiple flies in food prep and serving areas. The DM stated some items were expired or lacked use-by dates, and the IP noted proper food storage and sanitation were important for the resident population.
Pest control was not effective when flies were observed in a resident’s room, on another resident’s bedsheet, and throughout the kitchen and tray line while food was being prepared. A resident said flies had been in his room more than once, a family member said the flies were worse than normal, and the Dietary Mgr said she was not aware of anything being done beyond killing flies and wiping the area. The Admin said pest control was under the Maintenance Director, the facility had monthly exterior spraying, and he had not contacted the pest control company about the fly issue.
Failure to Maintain Privacy During Telemedicine Consultation: A resident with heart failure, hyperlipidemia, and a hip fracture, and who was cognitively intact, participated in a telemedicine psych consult in her room while a behavior health technician conducted the visit loudly enough for the roommate and surveyor to hear the discussion and answers. Staff were also observed entering the room without knocking or asking permission, despite staff training and facility policy requiring privacy, knocking, and introduction before entering or providing care.
A resident with DM, CKD, and moderate cognitive impairment reported that his phone was missing and said another resident had gone into his room before his wallet and phone disappeared. The facility searched the room and building but did not document the complaint in progress notes, did not document resident or staff interviews, and did not promptly report the allegation as possible exploitation/misappropriation. The Administrator later said the issue was reported to the state only after it was identified as stolen, while the facility policy required investigation of all possible incidents of abuse or misappropriation.
Medication orders were not followed for a resident with DM, CKD, and moderate cognitive impairment. The resident received insulin lispro when BS readings were above the ordered threshold without documentation that the MD was notified or that the hyperglycemic protocol was followed, and PRN oxycodone-acetaminophen was given when pain was rated 0, outside the ordered pain parameters. The RN and DON both stated the orders should have been followed as written.
Failure to Provide Individualized Activity Program: A resident with COPD, generalized weakness, difficulty walking, and moderate cognitive impairment was not provided an ongoing activity program that reflected her stated interests. Her care plan and activity assessment identified interests such as music, pets, arts and crafts, gardening, religious services, and social interaction, but activity records showed little documentation of offers or participation, and staff interviews confirmed she had not been personally invited to activities. The resident said she did not know about the activity schedule, could not read it without her glasses, and wanted help getting to activities and meeting other residents.
Missed Lab Order and No Documentation of Ordered Testing: A resident with multiple medical and psychiatric diagnoses had a physician order for a urinalysis reflex test and toxicology screen after staff observed slowed speech, pale skin, and unusual laughing and behavior. The MAR/TAR was left blank, the record contained no evidence the urinalysis was completed or resulted, and the DON confirmed the toxicology screen was not documented and the urinalysis was not collected.
Failure to Provide Recommended Speech Therapy Services: A resident with a history of stroke, aphasia, and severe communication impairment was screened by an SLP, who recommended a speech therapy eval after noting poor speech intelligibility and family request for services. However, the recommendation was not communicated to the MD or clinical team, and no ST order, auth request, or therapy visits were completed. Nursing notes continued to describe the resident as rarely or never understood and unable to form sentences or words.
A resident with cognitive impairment received a flu vaccine without documented consent, contrary to facility policy. Staff interviews revealed that the usual process of obtaining and verifying consent before vaccine administration was not followed, resulting in a deficiency in informed consent procedures.
A resident with dementia and dependence on supplemental oxygen received oxygen without a current physician's order. The resident's previous order was discontinued, yet progress notes and observations indicated ongoing oxygen use. A nurse confirmed the absence of an order and re-administered oxygen based on the resident's needs, contrary to facility policy requiring a physician's order. The DON acknowledged the policy breach.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure one resident was free from preventable accidents, including elopement. The resident was admitted with diagnoses including acute respiratory failure, dementia, hypertension, anxiety, difficulty walking, and weakness. A quarterly MDS assessment showed a BIMS score of 6, indicating significant cognitive impairment. The care plan noted impaired cognitive function related to dementia and stated the resident needed supervision and assistance with all decision making, with a consistent routine and consistent caregivers to reduce confusion. A behavior care plan also documented that the resident actively exit sought and made multiple attempts to leave through alarmed doors, and a wander risk evaluation identified the resident as high risk for wandering, with a known history of wandering at home and ambulation without assistance. On the morning of the incident, a receptionist was notified by a phone call from the community that it appeared the resident was walking down the street. Staff checked the resident’s room and dining room and did not find her. Staff then notified others in the facility to assist with a head count and complete a sweep, but the resident was not accounted for. Staff searched the surrounding area and located the resident several blocks away from the facility. The resident stated she was on her way to see the President. She was returned to the facility, assessed, and found to have no signs or symptoms of injury. An RN stated the resident had been seen in the dining room shortly before the elopement and had said she was going for a walk and would come back later. The RN stated it was normal for the resident to wander around the halls, and that the resident left the facility and was later retrieved after a community member reported seeing her walking down the street. The DON stated the resident had Alzheimer’s dementia and that the alarm on the door was functioning but was too quiet for staff to hear. The facility policy required residents at risk for wandering or elopement to be identified and have care plan strategies and interventions to maintain safety, and the resident’s record showed she was identified as high risk and actively exit seeking before the elopement occurred.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Unsafe Food Storage and Expired Food Items in Kitchen
Penalty
Summary
Food items were found stored and prepared under unsanitary conditions, and expired food items were present in the kitchen areas. During an initial kitchen observation with the dietary aide, surveyors found an undated and unnamed Styrofoam meal box containing 2 bologna sandwiches, a bag of shredded cheese dated July 29 to August 1, 2025, a container dated August 4, 2025 with a hard boiled egg, and an open Ziploc bag with cheese dated August 2, 2025. The dietary aide stated the facility used 2 days from the day the hard boiled egg was cooked because there was no use-by date for hard boiled eggs, and then discarded the Styrofoam meal box because it had no name or date. During the dry storage observation with the Dietary Manager, surveyors found an opened bag of hot dog buns and a large tub of mayonnaise with no opened or used-by dates. A large tub of BBQ sauce was dated July 16, 2025, and the Dietary Manager stated that date was the opened date and that the sauce did not have a use-by date. A box containing 6 to 7 heads of cabbage had multiple brown areas on the outside of each cabbage, and the Dietary Manager stated they would cut them in half to check the inside but would not serve them to residents. In the freezer, surveyors found a Ziploc bag of marinara sauce with an expiration date of July 9, 2025 and a Ziploc bag of cooked ham with an expiration date of July 17, 2025; the Dietary Manager stated both items were expired. During a puree meal preparation observation, multiple flies were seen in the kitchen area on the wall near the refrigerator entrance, on the tray line serving area, and on the drink preparation area. The Dietary Manager stated the administrator was aware of the fly issue, that a solution was being sought, and that kitchen staff killed flies and wiped the area where they were killed. The Infection Preventionist stated the resident population had an average age of 65 with weakened immune systems and age-related digestive changes, and that food had to be stored and served properly and outdated food discarded.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to ensure the environment was free from pests. On August 5, 2025, a resident was observed lying in bed with a hat over his face because of a fly in his room; he stated that he had had flies in his room a couple of times. On August 6, 2025, multiple flies were observed on the wall by the refrigerator, on the tray line in the kitchen serving area, and flying around the kitchen while puree was being prepared. During the same day, a fly was also observed on another resident’s bedsheet while he tried to shoo it away. A resident’s family member stated that flies were a problem and worse than normal that day, and said he had previously discussed air curtains for the outside doors with the Administrator. The Dietary Manager stated the Administrator was aware of the issue but she was not aware of anything being done, and said staff would kill the flies and wipe the area where they were killed. The Administrator stated the Maintenance Director was in charge of pest control, that the facility had a contract for monthly and as-needed exterior spraying, and that he had not contacted the pest control company about the fly issue even though he was aware of it. The facility policy stated that the facility shall maintain an effective pest control program.
Failure to Maintain Privacy During Telemedicine Consultation
Penalty
Summary
The facility failed to ensure that a resident was afforded privacy during a medical consultation. The resident was admitted with diagnoses including heart failure, hyperlipidemia, and a hip fracture, and the MDS documented a BIMS score of 12, indicating the resident was cognitively intact. A psych note dated August 5, 2025, documented that the resident participated in a telemedicine encounter with both audio and video components while located at the facility and sitting in a wheelchair in her room. During survey observation, a behavior health technician entered the resident’s room without knocking or asking permission and began conducting the telemedicine visit while the surveyor was interviewing the roommate. The doctor asked questions about the resident’s health, and the technician repeated the questions loudly because the resident was hard of hearing; the roommate and surveyor could hear the discussion and the resident’s answers. A therapy technician was also observed entering the room without knocking or asking permission. Staff interviews and the facility policy stated that staff are expected to knock, introduce themselves, and maintain privacy, and the DON stated that telemedicine should be conducted in a private area.
Failure to Report and Investigate Missing Resident Phone
Penalty
Summary
The facility failed to ensure that an allegation of exploitation involving a resident’s missing phone was reported and investigated. The resident was admitted with diagnoses including type II diabetes, acquired absence of an unspecified leg below the knee, and chronic kidney disease, and the MDS documented a brief interview for mental status score of 12, indicating moderate cognitive impairment. The resident reported that his phone had been missing since the weekend and said he saw another resident go into his room before his wallet and phone were missing. The room and facility were searched, but the phone was not found. The grievance documentation noted that the resident was to be reimbursed for the phone, but there was no documentation of the phone’s cost, and the progress notes did not include the resident’s complaint about the missing phone or his report of seeing another resident in his room. The Resident Relations Manager stated that a missing phone would be reported to the Administrator and that residents are usually reimbursed for missing personal property. She also stated that if there is a possibility of abuse, it must be reported to the Administrator, who reports it to the state agency and completes the investigation. The Administrator later stated that the allegation was reported to the state agency only after it was identified as stolen, and that the facility internally investigated and determined the phone was not stolen. He stated that the facility did not document interviews with residents or staff, although staff said they talked to residents near the room. The facility policy stated that it must identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.
Medication Orders Not Followed
Penalty
Summary
The facility failed to ensure medications were administered as prescribed for one resident with type II diabetes, an acquired absence of a leg below the knee, chronic kidney disease, and moderate cognitive impairment. The resident had orders for insulin lispro by sliding scale before meals and at bedtime, with instructions to notify the physician if blood sugar was 351 or over and to follow the hyperglycemic protocol. The resident also had an order for oxycodone-acetaminophen 5-325 mg every four hours as needed for pain rated 7-10. The care plan identified that the resident was dependent on insulin for diabetes management and was on opioid medication. During review of the July 2025 MAR, staff identified that the resident's blood sugar was 356 and 371 on two occasions, and 13 units of insulin were administered each time. The RN stated the physician should have been notified and the hyperglycemic protocol followed, but there was no documentation that the physician was notified and no additional blood sugar checks were documented. The same review showed oxycodone-acetaminophen was administered when the resident's pain level was 0, which was outside the ordered pain parameters. The DON stated that insulin should be given according to the sliding scale order and that PRN pain medication should follow the ordered pain scale parameters.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of Resident #12. The resident was admitted with diagnoses including pleural effusion, thoracic aortic ectasia, COPD, difficulty walking, and generalized muscle weakness. The physician orders allowed participation in the overall activity plan and exercise program, and the admissions activity assessment documented interests such as listening to music, going outside for fresh air, being around animals, favorite activities, religious services or practices, arts and crafts, gardening/arranging, and pets. The assessment also noted a need for reading glasses and identified music as a holistic intervention for pain, anxiety, and behaviors. The care plan identified previous recreational interests and patterns including meeting with friends, time alone, and watching TV, and noted the resident was dependent on staff for activities, cognitive stimulation, and social interaction. Interventions included providing leisure supplies, introducing the resident to others with similar interests, offering a variety of activity types and locations, assisting with community activities and transportation, and providing ADL assistance and escort to activity functions. The MDS showed moderate cognitive impairment, and the resident required partial to moderate assistance with wheelchair use and was usually understood with some difficulty communicating. Review of the activity task documentation for arts and crafts, group programs, music, special events/parties/socials, spiritual services, room visits, cultural activities, and bingo did not show whether the resident was offered or participated in activities, except for one special event marked yes and one room visit marked refused. There was no activity participation progress note documentation since admission. The resident stated she did not know about the activity calendar, had not been invited or told about daily activities, and would like to attend. She also stated she could not use a puzzle book because she did not have her reading glasses and could not read the activity schedule posted on her cupboard without them. Staff interviews confirmed that staff were expected to personally invite residents to activities, and the Activities Manager stated there was no documentation showing activities were offered or refused for each identified area of interest and that August 6, 2025 was the first day staff had offered an activity to the resident.
Missed Lab Order and No Documentation of Ordered Testing
Penalty
Summary
The facility failed to ensure a physician order was followed for one resident regarding a laboratory order for a urinalysis reflex test and toxicology screen. The resident was re-admitted with multiple diagnoses including pneumonitis due to inhalation of food, acute respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, repeated falls, adult failure to thrive, a history of sudden cardiac arrest, anxiety disorder, major depressive disorder, cannabis use in remission, contracture of muscle, paranoid schizophrenia, and bipolar disorder. A quarterly MDS assessment showed a BIMS score of 15, indicating intact cognition, and no behavioral symptoms were documented in Section E. A physician order directed that the urinalysis reflex test and toxicology screen be completed, with the toxicology screen able to be done in-house. A health status note documented that the resident was talking slowly, had pale-looking skin, and then began laughing and acting out of the ordinary, with the nurse noting the resident was not behaving as usual and notifying the physician. Review of the MAR/TAR showed the order was left blank with no evidence it was completed, and the clinical record contained no evidence of the urinalysis reflex test or toxicology screen, no results, and no communication regarding the order. Interviews with the Medical Records Manager, an RN, and the DON confirmed that no urinalysis results could be located, that the toxicology screen was not documented, and that the urinalysis was not collected.
Failure to Provide Recommended Speech Therapy Services
Penalty
Summary
The facility failed to ensure speech therapy services were provided for a resident with a history of stroke and significant communication impairment. The resident had diagnoses including aphasia following cerebral infarction, dysphagia, contractures, epilepsy, and cerebral infarction. The care plan documented that the resident had a communication problem due to stroke, was unable to form words, and communicated with sounds, gestures, and tone. Nursing documentation also described the resident as rarely or never understood when expressing ideas and wants, with aphasia and use of sounds or gestures for communication. A therapy services screen completed by an SLP identified poor speech intelligibility after CVA and noted that the resident's family had requested speech therapy services. The screen documented impaired ability to verbalize simple and complex ideas and impaired intelligibility, and it recommended a speech therapy evaluation. However, the clinical record showed no evidence that the recommendation was communicated to the physician or clinical team, no speech therapy orders were present, and no speech therapy services were provided at that time. Later nursing summaries continued to describe the resident as unable to form sentences or words and rarely or never understood. During interviews, the DOR stated that no speech therapy evaluation was completed in 2024 and that no therapy screens were conducted in 2025. The DON stated that when a resident or family requests therapy and a licensed clinician screens the resident and identifies the need for further evaluation, staff should follow physician orders and provide the recommended rehab services. The DON also stated that the January 2024 speech therapy screen had not been communicated to the physician or the rest of the clinical team, which resulted in no physician order, no insurance authorization request, and no subsequent therapy visits for the resident.
Failure to Obtain Informed Consent for Flu Vaccine
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of the flu vaccine prior to its administration. This deficiency was identified through a review of clinical records, facility documentation, interviews, and facility policy. The resident in question was admitted with several diagnoses, including cerebral infarction due to embolism, dysphagia, type 2 diabetes mellitus, and major depressive disorder, and had a moderately impaired cognitive status. Despite the facility's policy requiring informed consent for vaccinations, there was no documented consent for the influenza vaccine administered to the resident in 2023. Interviews with facility staff, including registered nurses, the medical records manager, and the director of nursing, revealed that the process for obtaining and documenting consent was not followed in this instance. The staff described a procedure where consent forms are provided and explained to residents or their representatives, scanned into electronic records, and verified before vaccine administration. However, in this case, the consent for the 2023 flu vaccine was missing from the resident's records, indicating a lapse in the facility's adherence to its own policies and procedures regarding informed consent for vaccinations.
Oxygen Administration Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for oxygen administration prior to its use. The resident, who was admitted with diagnoses including dementia and dependence on supplemental oxygen, had an order for oxygen that was discontinued in September 2023. Despite this, progress notes from September and December 2023, as well as observations in July 2024, indicated that the resident was receiving 2 liters of oxygen via nasal cannula without a current physician's order. The resident's Minimum Data Set assessment also did not reflect the use of oxygen therapy. During an observation in July 2024, a registered nurse confirmed the absence of a current order for oxygen and stated that the resident's family had requested comfort care measures, which initially included no oxygen. However, the nurse re-administered oxygen after assessing the resident's need, without obtaining a renewed order. The Director of Nursing confirmed that the facility's policy required a physician's order for oxygen administration, which was not followed in this case. The facility's policies on medication orders and oxygen administration emphasized the necessity of a physician's order specifying the rate of flow, route, and rationale for oxygen use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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