Haven of Douglas: Accident Hazard Violations - AZ
The October incident exposed multiple safety failures at the facility. The side door alarm system worked but was too quiet for staff to hear, according to the director of nursing.
Resident #100 had been admitted months earlier after her family could no longer care for her at home. She had become behavioral, suffered a fall that resulted in a fracture, and came to the facility for rehabilitation services. Her sister-in-law told staff she used to take morning walks at home, prompting the facility to arrange supervised walks with a nursing assistant.
On the morning of the escape, registered nurse staff member #20 arrived at 6 a.m. for his shift. Around 8 a.m., while he was doing wound care and other nurses were passing medications, he saw the resident in the dining room.
"She said she was going for a walk and said I'll come back later," the nurse told inspectors. He noted it was normal for the resident to wander the facility hallways.
Minutes later, the front office secretary alerted him that someone from the community had called to report seeing the resident walking down the street.
Staff conducted a head count and went to retrieve her. The resident was assessed and found to have no injuries from the incident.
When inspectors interviewed the resident days later, she pointed to an abrasion on her leg and said she was "still dealing with this one." She explained that "something was chasing her and she slipped and scraped her knee" but couldn't remember how it happened.
The resident told inspectors she didn't remember going for a walk, suggesting "it was probably her sister that left." She added that she goes for a walk every day. Inspectors noted she was a poor historian during the interview.
The director of nursing acknowledged the facility's failure. "It doesn't meet her expectations that the resident eloped," according to the inspection report.
The nursing director couldn't determine exactly how the resident escaped but suspected she used a side door equipped with an alarm system. The alarm functioned and was triggered when the door opened, but staff couldn't hear it.
"The alarm itself was too quiet for the staff to hear it because it was too quiet," the director told inspectors.
After the escape, staff discovered the resident had developed a urinary tract infection. The facility placed her on one-to-one monitoring with a dedicated sitter to prevent future incidents.
The facility's own policy requires identifying residents at risk of unsafe wandering and developing care plan strategies to maintain safety while using the least restrictive environment possible.
The nursing director told inspectors the alarm system was being replaced as part of their response to prevent similar incidents.
The resident remains under continued monitoring related to the elopement. She is described as alert and oriented to person and place but requires reorientation and redirection as needed. Her bed is kept in the lowest position with call light and water within reach, and she has a safety mattress in place.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven of Douglas from 2025-11-20 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 21, 2026 · Our methodology
HAVEN OF DOUGLAS in DOUGLAS, AZ was cited for violations during a health inspection on November 20, 2025.
The October incident exposed multiple safety failures at the facility.
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.