Resthaven Care Center

In the surveyor’s words

From the most serious findings on record at Resthaven Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 5, 2025

  This citation pertains to intake # 2574196Based on interview and record review the facility failed to ensure the safety of 1 resident (Resident #1) of 3 residents reviewed for accidents/hazards resulting in Resident #1 having a fall in the facility parking lot while she was left unattended and as a result suffered frontal and temporal lobe hemorrhages, a 4th left rib fracture and a change in capacity.Findings include:Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including cerebral infarction (stroke), chronic fatigue and cognitive communication deficit. R1 was in the hospital from [DATE] to 7/16/2025. […]

• Actual harm, isolatedF686Jan 14, 2022

  Based on observation, interview, and record review, the facility failed to prevent a facility acquired pressure ulcer and provide pressure ulcer preventative care and monitoring consistent with professional standards of practice for 1 out of 4 residents (Resident #79) reviewed for pressure injuries, resulting in the development and worsening of a Stage III pressure ulcer on the sacrum (coccyx), the development of a pressure injury on left lateral ankle, and the potential for skin breakdown and overall deterioration in health status. Findings include: Review of an Admission Record revealed Resident #79 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jun 6, 2024

  Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 11:09 AM on 6/4/24, observation of the Blueair Refrigeration unit found the digital thermometer on the outside stated it was 34F. Upon opening the door it was noticed that the ambient temperature of the unit felt warm and there was no ambient air thermometer in the unit. A temperature of an open half gallon of fat free milk was taken with a digital rapid read thermometer and found to be 55F. […]

• No harm, potential for more than minimal, widespreadF880Jun 6, 2024

  Based on observation, interview, and record review the facility failed to: 1.) ensure resident shared equipment was properly cleaned and sanitized between each use, 2.) ensure personal protective equipment (PPE) was worn by staff and visitors in care units where required and by staff when caring for 1 (Resident #119) of 29 sampled residents, 3.) ensure clean laundry bins used for transport were free from dirt and debris; and 4.) ensure 1 (Resident #91) of 2 residents sampled for dialysis had a dressing applied to their dialysis access site (an indwelling device). These deficient practices resulted in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. […]

• No harm, potential for more than minimal, widespreadF812Apr 26, 2023

  This citation pertains to intake number MI00133713 Based on observation, interview, and record review the facility failed to: 1. Ensure proper working order of the dish machine; 2. Datemark and discard potentially hazardous foods; 3. Store raw animal product in a manner that decreases contamination of ready to eat foods; and 4. Properly store clean and sanitary items and equipment. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 142 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 12:20 PM on 4/24/23, it was observed that the pressure indicator for the rinse cycle was reading between 50 and 55 pressure per square inch (psi). […]