Thomas Rest Haven

In the surveyor’s words

From the most serious findings on record at Thomas Rest Haven, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 15, 2026

  Based on observation, staff interviews, clinical record review and nursing standard of practice, the facility failed to ensure that staff used safe transfer techniques and fall preventions for 1 of 3 residents reviewed. Resident #1 had frequent falls and a history of self-transferring, the staff failed to use a gait belt while transferring, and failed to ensure the intervention of slip proof strips on the floor was implemented. The facility reported a census of 33 residents. The facility corrected the deficiency practice per past non-compliance on 1/7/26 through the following actions:*Nursing staff re-education on fall prevention, proper transfer techniques, mandatory use of gait belts and accountability for care plan compliance. […]

• Actual harm, isolatedF689Apr 9, 2025

  Based on observation, clinical record review, staff interview, and policy review the facility failed to provide adequate nursing supervision to prevent an accident and injury by leaving a resident that needed assistance with transfers, was a high risk for falls, and care planned to not leave unattended in the bathroom, unattended on the toilet and the resident fell and received an abrasion to the elbow and abrasion to the hip/buttock for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) for Resident #1, dated 1/23/25, documented a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment for decision-making. […]

• Actual harm, isolatedF689Apr 6, 2022

  Based on observations, clinical record reviews, and staff interviews, the facility failed to adequately supervise residents at risk for falls for 2 of 3 residents reviewed (Resident #190 and #32). Resident #190 had a history of trying to get up by himself and not waiting for the staff to help him. Resident #190 required staff assistance of one with transfers. On 9/19/21, as a different resident walked by Resident #190's room, they noticed him on the floor. The other resident called for staff assistance. Once staff arrived they discovered Resident #190 lying on his left side complaining of pain to his left hip. Despite observing Resident #190 on his left side and complaining of pain to his left hip, three staff members assisted him off the floor and into his bed. […]

• No harm, potential for more than minimal, widespreadF801Jul 27, 2023

  Based on staff interviews the facility failed to employ a staff member with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a qualified professional serve as the dietary manager. The facility reported a census of 33 residents. Findings include: On 7/25/23 at 11:32 AM the Dietary Manager reported that she did not have the education and training required for a qualified professional to serve as the Dietary Manager at the facility. She added that she is taking the classes to become certified. On 7/25/23 at 11:45 AM the Director of Nursing (DON) revealed she expected the facility to have a Certified Dietary Manager in charge of the kitchen.

• No harm, potential for more than minimal, widespreadF880Jul 27, 2023

  Based on staff interviews the facility failed to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in the facilities building water systems such as by having a documented water management program. The facility also failed to have an assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread and measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. […]