Haven Of Douglas
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
continues to be monitored related to an elopement incident. No injuries or impairments noted this shift.
Resident is alert and oriented A&Ox2 and is re-oriented and redirected as needed. Resident is currently in bed at lowest position with call light and water within reach. Safety mattress in place. An interview was conducted with a Registered Nurse (RN staff/#20) on October 23, 2025, at 10:58 a.m. The RN stated that
during the shift where the resident eloped he got to the facility at 6 in the morning. He stated that he was doing wound care, and the other nurses were doing medication pass at about 8ish, he remembered seeing resident #100 when he went to the dining room. He stated that resident #100 said she was going for a walk and said I'll come back later. Staff #20 further stated it's normal for the resident to wander around the halls of the facility, but that a few minutes later the secretary at the front office notified him that a community member had notified the facility that the resident was walking down the street. He further stated that after doing a head count they went down the street to retrieve the resident who stated she was going to see the president. Staff #20 concluded that the resident did leave the facility and was returned, assessed and found to have no injuries. An interview was conducted with resident #100 on October 23, 2025, at 12:03 p.m.
Resident #100 stated so far so good when asked about recent events, and that I'm still dealing with this one while pointing to an abrasion on her leg. The resident stated she doesn't know how it happened, that something was chasing her and she slipped and scraped her knee. Resident #100 stated she does not remember going for a walk, and that it was probably her sister that left. She concluded that she goes for a walk every day. However, it was noted the resident was a poor historian in the interview. An interview was conducted with the Director of Nursing (DON staff/#55) on October 23, 2025 at 12:20 p.m. The DON stated
she was aware of the incident with resident #100, and that resident #100 was admitted from home several months ago because the family could no longer take care of her. The DON stated that resident #100 has Alzheimer's dementia, and was behavioral at home, had a fall resulting in a fracture at home, and that's how she ended up in the facility for rehabilitation services. The DON stated that resident #100's sister in law identified that she used to go for morning walks and that's why they had RNA doing supervised walks with
the resident. The DON stated that she can't be 100% sure how resident #100 got out but since they didn't see her go out of the front door she thinks it was a side door with an alarm. The DON further stated that the alarm on the door was functioning and did trip the alarm, but that the alarm itself was too quiet for the staff to hear it because it was too quiet. The DON further stated that after the incident the resident was noted to have a urinary tract infection and that resident #100 was placed on 1:1 monitoring with a sitter to prevent further incidents. The DON concluded that it doesn't meet her expectations that the resident eloped and that the alarm was being replaced as part of all their interventions to assure this doesn't happen again. A
review of facility policy titled ‘Behavior / Mood / Cognition: Wandering and Elopements dated January 1, 2024, revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. It further revealed that if a resident is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.
Event ID:
Facility ID:
If continuation sheet
HAVEN OF DOUGLAS in DOUGLAS, AZ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DOUGLAS, AZ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HAVEN OF DOUGLAS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.