Haven of Douglas: Abuse Reporting Failures - AZ
The next night, Resident 1 pushed Resident 2 out of his room.
When federal inspectors arrived at the Douglas, Arizona nursing home on August 28, they found that neither incident had been properly reported or investigated, that wound documentation contradicted what the on-call nurse later told them, and that the two top leaders of the facility, the administrator and the director of nursing, were both out of town and unreachable on the day of the inspection.
The inspection was triggered by a complaint. What inspectors found earned the facility a deficiency citation under federal abuse prevention standards.
The registered nurse at the center of both incidents, identified in the inspection report as Staff 22, was on call the weekend of August 16 and 17, 2025. She received the calls for both incidents. Her explanation for why she didn't report the first one was straightforward: she had decided it was not physical, and therefore, in her view, it didn't require a report or an investigation.
She did not describe what criteria she used to make that determination. The inspection report does not indicate that anyone asked her to.
What happened to Resident 2 on August 16 is described in the report with some ambiguity. Resident 2 sustained a skin laceration. Staff 22 told inspectors that the laceration was not caused by Resident 1 but occurred when staff were trying to remove Resident 2 from Resident 1's room. She said she assessed the wound herself on Monday, August 18.
The records told a different story. The only skin and wound assessments documented in Resident 2's file were dated August 15, 2025, and August 22, 2025. Both of those assessments indicated no wounds to the skin. There was no August 18 entry. There was no entry documenting the laceration at all.
Staff 22's account of assessing the wound exists only in what she told inspectors. The paperwork doesn't support it.
The second incident, the night of August 17, was not disputed. Resident 1 pushed Resident 2 out of his room. LPN Staff 21, the care coordinator who was interviewed alongside Staff 22 on the afternoon of August 28, confirmed it happened. Staff 22 acknowledged it as well.
What happened after the second incident was not an investigation. Staff 21 described a meeting with Resident 1 and his family to arrange outside psychological services. Staff placed a Velcro barricade across Resident 1's doorway to discourage other residents from wandering in.
Those responses address Resident 1's behavior going forward. They do not constitute an investigation into what happened to Resident 2 on either night, who was responsible, whether Resident 2 was safe, or whether the facility's abuse prevention obligations had been met.
Haven of Douglas's own written policy, dated January 1, 2024, states that residents have the right to be free from abuse by anyone, including other residents, and that the facility's abuse prevention program includes a commitment to protect residents from further harm during investigations. The policy envisions investigations happening. In this case, none did.
When inspectors tried to speak with the people most responsible for ensuring those obligations were met, they ran into a wall of absence. The administrator, identified as Staff 18, was reported to be in Canada. Staff told inspectors they were unable to reach him. The director of nursing was out of town and also unreachable. Both were unavailable on the same day inspectors came to examine a complaint about two resident-on-resident incidents that had occurred less than two weeks earlier.
The inspection report does not indicate that either leader was notified of the inspection in advance, or that either had been involved in the facility's response to the August 16 and 17 incidents in the days before inspectors arrived.
What the inspection report leaves open is what Resident 2 experienced across those two nights and in the days that followed. The report identifies Resident 2 as the person who was present during both incidents, who sustained a laceration that staff say they treated but that the records do not show, and who was pushed out of another resident's room on consecutive nights. The level of harm is characterized in the inspection report as minimal harm or potential for actual harm.
The Velcro barricade went up after the second night.
The inspectors who came to Douglas on August 28 spoke with Staff 21 and Staff 22 at 2:15 in the afternoon. They reviewed the wound assessment records. They reviewed the policy. They noted the gap between what the nurse said she had done and what the documentation showed. They noted that no report had been filed after the first incident and no investigation had been completed after either one.
The citation issued is for failure to protect residents from abuse, a deficiency that, at this facility on these dates, unfolded not through a single dramatic failure but through a series of smaller ones: a judgment call made alone on a weekend night, a wound assessment that no record confirms, a meeting with a family that substituted for an investigation, and two senior administrators who were not there when the questions finally arrived.
Resident 2's name does not appear in the inspection report. Neither does any account of what Resident 2 said about what happened, or whether anyone asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven of Douglas from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
HAVEN OF DOUGLAS in DOUGLAS, AZ was cited for abuse-related violations during a health inspection on August 28, 2025.
The next night, Resident 1 pushed Resident 2 out of his room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.