Thomas Rest Haven: Fractured Hand Missed for Days - IA
That was August 9, 2025. The resident left the facility three days later, on August 12, with the hand still unexamined by a physician, still unimaged, still undiagnosed. When he arrived at his next facility that same day, his wife immediately asked staff what they were going to do about his hand. A nurse there looked at it, saw the bruising and swelling, and sent him for an X-ray. The imaging report came back showing fractures of the fourth and fifth metacarpals, the bones running through the palm to the ring and pinky fingers.
The fractures were found within hours at the receiving facility. Thomas Rest Haven had the hand in front of them for days and never got that far.
A certified nursing assistant, identified in the inspection report as Staff B, said she had noticed the swelling and helped the resident's wife remove his ring because of it. She reported what she saw to the nurse on duty, identified as Staff C. His response, according to Staff B, was that the hand was okay and not broken. The wife had voiced concerns and wanted further assessment. Staff C did not call the doctor.
The administrator said she learned only later that the nurse had never made that call, despite her direct instruction to do so. She had come in at 4 a.m. She had looked at the hand. She had given a clear order. None of it produced a physician call, a follow-up assessment, or an X-ray.
What it produced was three more days of a man with broken bones in his hand and no diagnosis.
The inspection, a complaint survey conducted September 18, 2025, captured interviews from multiple staff and a representative from the receiving facility. The receiving facility's staff member said the wife's first question, when her husband was delivered on August 12, was about his hand. That detail matters: she wasn't raising a new concern. She had been raising it at Thomas Rest Haven and gotten nowhere.
The administrator told inspectors the wife had not expressed concerns about the swelling and had not asked for an X-ray. Staff B said otherwise. The receiving facility said otherwise. The wife's first words to a stranger at a new building were about that hand.
During the investigation into the resident's falls, the administrator also discovered that skin assessments had not been completed. The hand was not an isolated failure of documentation. It was one visible point in a broader pattern of assessments that weren't happening.
The facility's own nursing standards, cited in the inspection report, described what was required: document changes in resident condition, follow up with a plan, notify the physician as needed, and conduct per-shift assessments after any incident. The nurse who looked at a swollen, bruised hand and told the aide it was fine did none of those things. The fractures of the fourth and fifth metacarpals were sitting there, unrecognized, for the duration of the resident's remaining stay.
Inspectors cited the facility under F0684, which covers the quality of care residents receive, and classified the level of harm as minimal harm or potential for actual harm. Whether three days with undiagnosed hand fractures constitutes minimal harm is a question the citation doesn't answer.
What the record does show is that a woman watched her husband's hand swell, asked staff about it, helped a nursing aide pull off his ring because the swelling was that significant, asked again, and left that facility without anyone having called a doctor. She got to the next place and asked a third time. That time, someone listened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thomas Rest Haven from 2025-09-18 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 27, 2026 · Our methodology
Thomas Rest Haven in Coon Rapids, IA was cited for violations during a health inspection on September 18, 2025.
The resident left the facility three days later, on August 12, with the hand still unexamined by a physician, still unimaged, still undiagnosed.
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.