Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

DOUGLAS MANOR

WINDHAM, CT · 90 certified beds · Last Life Safety survey April 22, 2025

CMS Certification Number 075258 · first certified April 1976

Ownership

Operated by RYDERS HEALTH MANAGEMENT · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

11
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

Position within CT

11 citations — more than 53% of the 191 certified nursing homes in CT. Compared within CT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens February 2027 — about 4 months from now. This facility’s last Life Safety survey was April 2025. Facilities in CT are typically surveyed 21–28 months after the last one (median 24), measured over 181 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in CT, and nationally. Surveyors differ markedly between states, so the CT figure is the meaningful one.

This facility11CT median10National median11
Citations on file over three years, compared
MeasureCitations
This facility11
Median facility in CT10
Median facility nationally11

Survey history

Citations at each Life Safety survey
12020-0242023-0362025-04
Citations at each Life Safety survey
Survey dateCitations
February 5, 20201
March 13, 20234
April 22, 20256

Most-cited tags

Most-cited tags at this facility
K-05412K-03631K-03511K-09271K-02111K-07121K-07111K-03241
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0541Install properly constructed and protected linen or trash chutes.22025-04-22
K-0363Install corridor and hallway doors that block smoke.12023-03-13
K-0351Install an approved automatic sprinkler system.12025-04-22
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.12025-04-22
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12025-04-22
K-0712Have simulated fire drills held at unexpected times.12025-04-22
K-0711Provide a written emergency evacuation plan.12023-03-13
K-0324Provide properly protected cooking facilities.12023-03-13

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 4
  • Miscellaneous Deficiencies 2
  • Services Deficiencies 2
  • Construction Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies4
Miscellaneous Deficiencies2
Services Deficiencies2
Construction Deficiencies1
Gas, Vacuum, and Electrical Systems Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 22, 2025 — 6 citations

Citations issued on April 22, 2025
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (July 16, 2025)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (July 16, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (July 16, 2025)
K-0541Install properly constructed and protected linen or trash chutes.Deficient, Provider has date of correction (July 16, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (July 16, 2025)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (July 16, 2025)

March 13, 2023 — 4 citations

Citations issued on March 13, 2023
TagWhat the surveyor checksStatus
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (April 21, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (April 21, 2023)
K-0541Install properly constructed and protected linen or trash chutes.Deficient, Provider has date of correction (April 21, 2023)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (April 21, 2023)

February 5, 2020 — 1 citation

Citations issued on February 5, 2020
TagWhat the surveyor checksStatus
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (February 11, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.