Resthaven Living Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 24, 2023

  Based on record reviews and interviews, the facility failed to ensure the residents remained as free of accident hazards as possible for each resident who was transported in the facility's van via wheelchair for 1 (#2) of 8 (#1, #2, #3, #4, #5, RR#1, RR#2, RR#3) residents reviewed for transportation/accidents. The facility failed to secure Resident #2's safety (belt) during transport as recommended by manufacturer guidelines. This failed practice resulted in an actual harm for Resident #2 on 03/27/2023 when Resident #2, who was not properly restrained, slid out of her wheelchair while being transported. […]

• No harm, potential for more than minimal, widespreadF812Dec 8, 2022

  Based on observations and interviews, the facility failed to store, prepare food and maintain kitchen equipment under sanitary conditions by failing to ensure: 1. Food items were properly stored in the walk-in refrigerator; 2. Food items were properly stored in the food prep area; 3. Raw, uncooked food items were properly stored in the food prep area; and 4. Stationary equipment used in the kitchen was clean and free from debris. This deficient practice had the potential to affect 96 residents who ate from the facility's kitchen. […]

• No harm, potential for more than minimal, patternF759Jan 14, 2026

  Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% by failing to give medications as ordered for 2 (#67 and #85) of 5 residents observed during medication administration. A total of 25 opportunities were observed with 3 medication errors, which resulted in a medication error rate of 12.00%. Findings: Review of the facility's policy titled, Administering Medications with revision date April 2019 revealed the following, in part:Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3. Medications are administered in accordance with prescriber orders, including any required time frame. 9. […]

• No harm, potential for more than minimal, patternF812Jan 14, 2026

  Based on observations and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure:1. The ice machine was maintained in safe operating and sanitary condition; and2. Pots and pans were sanitized.This deficient practice had the potential to affect all 81 residents who ate from the kitchen. Findings: 1. On 01/11/2026 at 8:30 a.m., an observation was made of the ice machine in the kitchen with a low level of ice mixed with pink sludge. Further observation revealed pink sludge in the right front corner. On 01/11/2026 at 8:34 a.m., an interview was conducted with S3DM. She stated the ice machine was serviced and cleaned on 01/09/2026. […]

• No harm, potential for more than minimal, patternF814Jan 14, 2026

  Based on observation and interviews, the facility failed to ensure refuse containers were in good condition and waste was properly contained. This deficient practice had the potential to affect 82 residents residing in the facility. Findings: On 01/11/2026 at 9:15 a.m., an observation was made of a large open bulk grease disposal container outside, next to the facility wall, behind the kitchen with the lid open. A further observation was made of a large amount of black grease on top of the container and on the surrounding concrete area with leaves mixed in. On 01/11/2026 at 9:16 a.m., an interview was conducted with S3DM. She stated the bulk grease disposal container was in poor condition. […]