Thomas Rest Haven: Fractured Hand Left Untreated - IA
The resident's wife noticed the swelling first. When staff finally looked at the hand, they found it bruised and swollen. An X-ray taken on August 12, 2025, confirmed fractures of the fourth and fifth metacarpals on the left wrist.
The administrator told inspectors she had come into the facility at 4 AM on August 9 after a nurse flagged the swollen hand. She looked at it herself, then told the nurse to call the doctor and document what he found. She found out later he had done neither.
The administrator said the wife had not expressed concerns about the swelling and had not asked for an X-ray. The wife's account, as reflected in the inspection record, was the opposite: she asked immediately what was going to be done about his hand.
Nobody called the doctor. The nurse saw the hand. The administrator saw the hand. The order was given. And then nothing happened.
The failure surfaced during a broader investigation into the resident's falls. While looking into those incidents, the administrator discovered that skin assessments were not being completed either. The fracture case was not an isolated lapse in an otherwise functioning system. It was one crack in several.
The facility's own nursing standards document, used to train staff, states that any change in a resident's condition must be followed up with an appropriate plan, physician notification as needed, and per-shift assessments documented on a hot chart form after any incident.
The nurse did not follow up. The physician was not notified. Whether any per-shift assessments were completed in the hours after the hand was first seen swollen, the inspection record does not say.
The resident's wife had to ask what anyone was going to do about her husband's hand. The answer, for a significant stretch of time, was nothing.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
Thomas Rest Haven in Coon Rapids, IA was cited for violations during a health inspection on September 18, 2025.
The resident's wife noticed the swelling first.
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.