Thomas Rest Haven: Fall Injuries Unreported to Doctor - IA
Federal inspectors cited the 31-bed nursing home following a complaint inspection completed September 18, 2025. The single deficiency, rated at minimal harm or potential for actual harm, centered on one resident identified in the report as Resident #31.
The resident was a man with a BIMS score of 1, indicating severe cognitive deficits, and diagnoses that included cancer, anemia, deep venous thrombosis, and dementia. He had been admitted for respite care with plans to return home. By early August 2025, he was falling repeatedly, most often after 10 p.m.
The first documented fall came on August 2, when staff found him on the floor in front of the television at 3:59 p.m. A nurse took his vitals, which were within normal limits, and completed a skin and neurological assessment. The chart contained no documentation of anyone contacting his physician or his family.
Five days later, at 2:40 a.m. on August 7, he was found on the floor on his side near his door. This time he had a skin tear to his left wrist, another to his left elbow, and injuries to his back ribs. Again, the chart showed no notification to the doctor or to family.
Then August 9 arrived.
At 2:02 a.m., staff documented bruising across the top of his left hand and swelling. Less than three hours later, at 4:33 a.m., a new entry described a purple bruise measuring 7 centimeters by 4 centimeters on his left rear flank. The chart noted that the medical doctor was not notified about the wound. By 9:56 a.m. that same morning, a third entry described an abrasion to the top of his scalp and the swollen, bruised left hand again. The chart lacked documentation of any doctor notification about the hand.
The administrator told inspectors that she had come in at 4:00 a.m. on August 9, personally examined the swollen hand alongside the overnight nurse, and directed that nurse to call the doctor and document the contact. She said she found out later the call was never made. She acknowledged to inspectors that the doctor and family should have been contacted after falls and injuries.
The overnight nurse who handled many of these incidents, a licensed practical nurse identified as Staff H, told inspectors on September 15 that most of Resident #31's falls happened after 10 p.m. His explanation for why physicians weren't called: if it wasn't an emergency, day shift would handle notifications the next morning.
The facility's own nursing standards document, dated 2024, stated plainly that changes in condition must be followed with an appropriate solution or plan, and that physicians should be notified as needed for further direction. A separate section required staff to set up follow-up assessments each shift after any incident.
The gap between what that document required and what staff actually did played out across seven days and at least five separate incidents involving a man who could not advocate for himself. His BIMS score of 1 placed him at the most severe end of the cognitive impairment scale. He had wandering behaviors occurring one to three days a week. His care plan noted he was at risk for skin breakdown because of fragile, thin skin. He was, in other words, exactly the kind of resident for whom physician notification after a fall is not a formality.
By August 7, before the worst of the August 9 injuries were documented, the facility had already accepted him for transfer to a locked unit at another facility. What happened to him in those final days at Thomas Rest Haven, and whether the injuries to his hand and flank were ever properly evaluated by a physician, the inspection report does not say.
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: 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 19, 2026 · Our methodology
Thomas Rest Haven in Coon Rapids, IA was cited for violations during a health inspection on September 18, 2025.
Federal inspectors cited the 31-bed nursing home following a complaint inspection completed September 18, 2025.
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.