Haven of Douglas

In the surveyor’s words

From the most serious findings on record at Haven of Douglas, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Aug 7, 2025

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure that food items were stored and prepared under sanitary condition; and failed to ensure that expired food items were discarded. The deficient practice could result in unsafe food storage, placing residents at risk for foodborne illnesses.Findings include: During an initial kitchen observation conducted with the dietary aide (staff #70) on August 5, 2025 at 10:25 a.m. there were undated and unnamed Styrofoam meal box of 2 bologna sandwiches, 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. […]

• No harm, potential for more than minimal, patternF925Aug 7, 2025

  Based on observations, resident and staff interviews and facility policy review, the facility failed to ensure the environment was free from pests. The deficient practice could result in the spread of germs. Findings included: On August 5, 2025 at 11:58 a.m. the resident was observed laying on his bed with a hat over his face. The resident was awake and stated that he put the hat on face because of the fly. A fly was observed flying around the resident's room and he stated that he has had flies in his room a couple of times. On August 6, 2025 at 11:09 a.m. multiple flies were observed on the wall by the refrigerator, on the tray line (serving area), and flying around in the kitchen, while observing the puree being prepared. […]

• No harm, potential for more than minimal, isolatedF689Nov 20, 2025

  Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in life-threatening injuries.Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in life-threatening injuries.Findings include: -Resident #100 was admitted to the facility on [DATE] with diagnoses that include acute respiratory failure, dementia, hypertension, anxiety, difficulty walking, and weakness. […]

• No harm, potential for more than minimal, isolatedF600Aug 28, 2025

  Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of one resident (# 2) to be free from abuse by another resident (# 1). The deficient practice could result in other residents being abused. Regarding Resident # 1: Resident # 1 was admitted on [DATE], with diagnoses that included [NAME] Syndrome, adjustment disorder, and major depressive disorder.A care plan dated March 19, 2020, revealed that Resident # 1 exhibited behavior problems, including becoming very angry and agitated when another resident or roommate accidentally sits in his chair or accidentally touches personal items. […]

• No harm, potential for more than minimal, isolatedF583Aug 7, 2025

  Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#56) was afforded privacy during a medical consultation. The deficient practice could result in residents' rights to privacy not being respected. Findings included: Resident (#56) was admitted to the facility on [DATE] with diagnoses that included heart failure, hyperlipidemia, and a hip fracture. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact. A psych note completed on August 5, 2025 at 12:15 p.m. […]