Haven of Douglas: Resident Attack, Missing Records - AZ
That gap, seven days straddling two physical altercations between residents, sits at the center of a complaint inspection completed August 28, 2025, at the Douglas nursing facility. What inspectors found was not a single lapse but a sequence: an attack, a second attack three days later, a nurse whose account of her own clinical work did not match the written record, and a facility that placed a Velcro strip across a doorway and called it a protective measure.
The first incident involved Resident 1 and Resident 2. The inspection report does not describe the nature of that initial altercation in detail, but it establishes that staff were present and attempting to remove Resident 1 from the room when the injury to Resident 2 occurred. The wound was not caused by Resident 2 himself, inspectors noted, but happened in the course of that removal.
What followed should have been straightforward. Assess the injury. Document it. Monitor both residents. Investigate.
The documentation that exists tells a different story. Skin and wound assessments from August 15th showed nothing. The next assessment on record was August 22nd. It also showed nothing. In between those two dates, a resident was physically harmed.
Staff 22, a licensed practical nurse, told inspectors she had personally assessed the wound on Monday, August 18th. When inspectors looked at the chart, that assessment was not there. The only records bracketing that date showed no wounds existed before the incident and no wounds were documented after it, until a week had passed. Staff 22 did not produce documentation of the August 18th assessment. She said she had monitored residents that night. She did not acknowledge, inspectors noted, that a second altercation had taken place on August 17th.
That second incident is its own entry in this sequence. One day before the nurse says she performed an undocumented wound check, Resident 1 pushed Resident 2 out of his room. It was the second time in days that these two residents had come into physical conflict. The facility's response, according to LPN Staff 21, was to hold a meeting with Resident 1 and his family to arrange outside psychological services. LPN Staff 22 said the facility placed a Velcro barricade across Resident 1's doorway.
The Velcro barricade was meant to stop other residents from wandering into the room.
Resident 2 had already been pushed out of that room twice.
Nursing homes are required to protect residents not only from staff but from one another. The facility's own policy, dated January 1, 2024, and titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, states that residents have the right to be free from abuse, and that the facility's prevention program includes a commitment to protect residents from further harm during investigations. The policy names other residents explicitly as a category of potential harm. It was in place. It did not prevent a second incident from occurring the day after the first.
What inspectors were examining was not whether the policy existed. It did. What they were examining was whether anything the facility actually did matched what that policy required.
The answer, across the documentation they reviewed and the staff interviews they conducted, was inconsistent at best.
Staff 22's account of an August 18th wound assessment that left no trace in the medical record is not a minor discrepancy. In a nursing facility, the record is the care. If an assessment was performed and not documented, there is no way to know what the nurse found, whether the wound was worsening, whether pain was present, whether any clinical decision followed from what she saw. If the assessment was not performed and the nurse misremembered or misstated her actions to inspectors, that is a different and more serious problem. The inspection report does not resolve which of those is true. It records only that she said she did it and the chart says she did not.
The inspection classified the harm level as minimal, with few residents affected. That classification reflects the regulatory framework inspectors apply, not a judgment that nothing serious happened. A resident was physically harmed by another resident. A second incident followed three days later. A nurse's clinical account could not be reconciled with the written record. The facility's protective response was a fabric strip across a doorway.
Douglas is a small city in Cochise County, in the southeastern corner of Arizona, near the border with Mexico. Haven of Douglas serves a community with limited options for long-term care. The residents who live there, including Resident 2, depend on the facility not only for housing but for safety. When two people come into physical conflict in a nursing home, the residents involved cannot simply leave. They cannot choose a different hallway or a different building. They are there, and the staff are responsible for what happens between them.
The sequence of events documented in this inspection does not suggest a facility that responded to the first incident with urgency. A second incident happened the next day. The nurse who said she assessed a wound between those two events has no documentation to support that account. The meeting with Resident 1's family happened after the second incident, not the first. The Velcro barricade went up after the second incident.
What happened to Resident 2 between August 15th, when the last clean skin assessment was recorded, and August 22nd, when the next one appeared, is not fully answered by the inspection report. The wound that Staff 22 said she evaluated on August 18th has no clinical record. Whether it was healing, infected, or worsening during that week is not something the documentation can answer, because the documentation from that period does not exist.
The inspection covered three pages. The narrative is brief. What it captures is a facility where a resident was hurt, a second incident followed before meaningful protective steps were taken, and a nurse's account of her own care could not be verified against anything written down at the time she says she wrote it.
Resident 2 was pushed out of a room. Then pushed out again.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
HAVEN OF DOUGLAS in DOUGLAS, AZ was cited for violations during a health inspection on August 28, 2025.
The first incident involved Resident 1 and Resident 2.
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.