Haven of Douglas

• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 20, 2025.

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• Star rating

  The CMS health inspection star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on September 25, 2025.

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CMS lists this as a standard inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on October 1, 2025.

• Citation F0925. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on October 1, 2025.

• Citation F0583. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on October 1, 2025.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on September 30, 2025.

  CMS has cited this home for F0609 2 times since 2023.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on October 1, 2025.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on October 1, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on October 1, 2025.

• Citation F0825. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or get specialized rehabilitative services as required for a resident.

  CMS lists it as corrected on October 1, 2025.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a standard inspection.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on August 30, 2024.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on August 30, 2024.

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CMS lists this as a standard inspection.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on August 30, 2024.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on September 4, 2024.

  CMS has cited this home for K0372 2 times since 2023.

• Citation K0914. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on September 4, 2024.

  CMS has cited this home for K0914 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation F0560. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect a residents' right to refuse some types of non-requested transfers within the nursing home.

  CMS lists it as corrected on March 20, 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on March 20, 2023.

• Citation F0732. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on March 20, 2023.

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CMS lists this as a standard inspection.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on March 20, 2023.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on March 20, 2023.

• Citation K0712. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on March 20, 2023.

• Citation K0914. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on March 20, 2023.

• Citation E0039. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on March 20, 2023.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on March 20, 2023.

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