Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thomas Rest Haven during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, morbid obesity, impaired balance, and a documented history of self-transferring and falls was care planned for specific fall interventions, including use of a gait belt during transfers, two-person assistance in some circumstances, a Hoyer lift for all transfers, and non-skid strips in the bathroom. Despite these directives and a high Morse Fall Scale score, staff did not consistently follow the care plan or standards of practice. After the resident was moved to a new room, anti-slip strips were not applied to the new bathroom floor, and on one occasion a CNA, unfamiliar with the care plan, assisted the resident into the bathroom without a gait belt; when the resident’s legs gave out while holding a grab bar, the CNA attempted to support her under the arms but could not prevent her from being lowered to the floor, resulting in fractures to the lower leg that were later classified as a major injury.
A resident with severe cognitive impairment and multiple medical conditions experienced several falls and injuries, including bruising, swelling, and skin tears. Staff did not notify the physician or family after these incidents, and documentation of follow-up actions was lacking, despite facility policy requiring such notifications and assessments.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents resulting in injuries, including abrasions, skin tears, and a swollen hand. Staff failed to complete and document required skin assessments, wound measurements, and timely notifications to the physician and family, despite facility policy and care plan requirements. Family concerns about the resident's untreated injuries were confirmed when fractures were discovered after transfer to another facility.
A resident with cognitive impairment and high fall risk, who required substantial assistance and was care planned to never be left unattended in the bathroom, was left alone on the toilet by a TNA who then went on break without notifying others. The resident attempted to get up unassisted, resulting in a fall with multiple abrasions and skin tears. Staff interviews confirmed the resident's supervision needs were documented and known, but were not followed, leading to the incident.
A facility failed to ensure staff documented the open date on a Vitamin B-12 bottle before administering it to a resident. An LPN administered the vitamin without an open date, later realizing the mistake after consulting with the Administrator. The resident had a BIMS score of 15 and a medical history including hypertension and Alzheimer's. The Administrator noted regular checks for open bottles but found no specific policy on open date documentation.
Two residents reported being instructed by staff to urinate in their briefs due to delayed assistance to the restroom, compromising their dignity. One resident, with moderate cognitive deficit, experienced stress and degradation, while another, with intact cognitive ability, was told he used his call light too often. The facility's administrator was unaware of these incidents, which violated the residents' rights to dignity and respect.
A resident with severe cognitive deficits and a history of attempting to get up on his own fell in the dining room due to inadequate supervision and the absence of a personal alarm on his chair. The fall resulted in a severe hip injury requiring surgery. Staff interviews revealed uncertainty about the alarm's presence and effectiveness, and observations showed ongoing challenges in managing the resident's fall risk.
A facility failed to complete and submit a resident's MDS assessment within the required timeframe. A resident was discharged, and the MDS was completed by the ADON but not submitted to CMS until much later. The DON acknowledged issues with the MDS process due to the former MDS coordinator's performance. The RAI Manual requires the MDS to be completed and submitted within specific timeframes.
Failure to Use Gait Belt and Implement Fall Precautions During High-Risk Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer techniques and fall prevention measures for a resident with a known history of frequent falls and self-transferring. The resident had moderate cognitive impairment (BIMS 11), required partial assistance with transfers and sit-to-stand, was always incontinent of urine, and had multiple comorbidities including hypertension, diabetes mellitus, COPD, and morbid obesity. Her care plan identified self-care deficits, impaired balance, poor safety awareness, and fall risk, and documented prior falls and the need for specific fall interventions, including non-skid strips in the bathroom, use of a Hoyer lift for all transfers as of 12/7/25, and staff education to use a gait belt when transferring. Nursing progress notes showed a pattern of self-transferring and fall-related events over several months, including documentation that the resident continued to self-transfer, had a witnessed fall during transfer to the toilet, and was being ambulated by staff when she reported her legs were giving out and was lowered to the floor. A Morse Fall Scale assessment scored her at 70, indicating high fall risk. Despite these documented risks and interventions, staff did not consistently follow the care plan and standards of practice. The resident’s care plan called for non-skid strips in the bathroom, but after she changed rooms on 12/3/25, the anti-slip strips were not implemented in the new bathroom. On the date of the major fall event, a CNA assisted the resident into the bathroom without applying a gait belt, despite having been educated on gait belt use and acknowledging she knew one should have been used. The CNA was behind the resident as the resident held onto a support bar; when the resident’s legs gave out, the CNA attempted to hold her by placing her arms under the resident’s armpits but was unable to keep her up and lowered her to the floor. Multiple staff confirmed that at the time of this fall the resident did not have a gait belt on, and that some staff typically used two-person assistance with a gait belt due to the resident’s size. The post-fall evaluation and emergency room X-ray documented fractures of the distal tibia and fibula, and a physician later determined the injury to be a major injury.
Failure to Notify Physician and Family After Resident Falls and Injuries
Penalty
Summary
Staff failed to notify the physician and family when a resident experienced multiple falls and injuries, including a bruised and swollen hand, skin tears, and abrasions. Documentation in the clinical record showed that after each incident, such as falls and the discovery of new injuries, there was no evidence that the physician or family were informed, nor were follow-up orders or directions obtained from the physician. The facility's own Nursing Standards of Practice required staff to notify the physician of changes in condition and to document follow-up actions, but these steps were not followed. The resident involved had severe cognitive deficits, a history of wandering, and multiple medical diagnoses including cancer, anemia, DVT, BPH, and dementia. Despite being at risk for impaired skin integrity and having a care plan that called for close monitoring, staff did not document required notifications after incidents. Interviews with staff and the administrator confirmed that notifications were not made as required, and that documentation and follow-up were lacking after the resident's injuries and changes in condition.
Failure to Assess and Document Injuries After Multiple Falls
Penalty
Summary
The facility failed to provide timely and accurate assessment and interventions for a resident with a history of multiple falls and significant cognitive impairment. Despite documented care plans requiring weekly treatment documentation and detailed skin assessments, staff did not consistently complete or document skin assessments, measurements, or descriptions of injuries following several falls. There was also a lack of documentation regarding notification of the physician and family after incidents resulting in visible injuries, such as abrasions, swelling, and bruising. The resident, who was admitted for respite care and had diagnoses including cancer, anemia, deep venous thrombosis, benign prostatic hyperplasia, and dementia, experienced multiple falls during the stay. On several occasions, the resident was found on the floor with injuries such as abrasions, skin tears, and swelling, but the clinical record lacked comprehensive skin assessments, wound measurements, and timely documentation of these injuries. Additionally, there was insufficient evidence that the physician or family was notified after these incidents, despite the care plan and facility policy requiring such actions. Family interviews revealed concerns about the lack of communication regarding the resident's injuries, particularly a swollen and bruised hand that was later found to have fractures upon transfer to another facility. Staff interviews indicated that assessments and follow-up actions were not consistently performed or documented, and there was confusion among staff regarding the need for further medical evaluation. Facility policy required follow-up assessments and physician notification for changes in resident condition, but these procedures were not followed in this case.
Resident Left Unattended in Bathroom Resulting in Fall and Injuries
Penalty
Summary
A resident with moderate cognitive impairment, non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, and depression was identified as high risk for falls and required substantial to maximal assistance with transfers and toilet use. The resident's care plan specifically included an intervention to not leave the resident unattended in the bathroom due to impaired balance, poor safety awareness, and a history of falls. Despite these documented needs and interventions, the resident was left alone on the toilet in the bathroom by a Training Nurse Assistant (TNA), who then left the area to retrieve a brief and subsequently went on a meal break without notifying other staff that the resident was unattended. The incident occurred when the TNA, after placing the resident on the toilet, left to find a larger brief and was then called to dinner by an LPN. The TNA, feeling intimidated and distracted, went to dinner and forgot to inform anyone that the resident remained in the bathroom. During this time, no other staff were aware of the resident's location or that he was left unattended. The resident attempted to get up unassisted, resulting in a fall that caused multiple injuries, including abrasions and skin tears to the elbow, hip, buttock, and hand, as well as visible bleeding and bruising. Staff interviews confirmed that the resident was not to be left alone on the toilet and that this information was available in the care plan, Kardex, and communication book. The facility had a system in place to highlight residents who should not be left unattended, and staff were expected to be knowledgeable about each resident's care needs. Despite these protocols, the failure to follow the care plan and provide adequate supervision directly led to the resident's fall and subsequent injuries.
Failure to Document Open Date on Medication
Penalty
Summary
The facility failed to ensure that staff were aware of the date a stock supplement had been opened before administering it to a resident. During a medication administration observation, a Licensed Practical Nurse (LPN) prepared Vitamin B-12 for a resident without a documented open date on the bottle. The LPN acknowledged the absence of an open date and proceeded to administer the vitamin to the resident. After consulting with the Administrator, the LPN realized the mistake and noted that in the future, unmarked bottles should be destroyed, and a new bottle should be used with the open date documented. The resident involved had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive function, and was independent in certain activities of daily living. The resident's medical history included hypertension, diabetes, Alzheimer's, anxiety, and depression. The Administrator mentioned that a nurse regularly checks the medication cart for open bottles without dates and that staff are instructed to document the open date when a bottle is first opened. However, the Administrator could not find a specific medication policy addressing open date documentation.
Failure to Maintain Resident Dignity in Incontinence Care
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the experiences of two residents. Resident #238, who had a moderate cognitive deficit and required assistance with activities of daily living, reported that staff instructed him to urinate in his adult brief when they could not assist him to the restroom in a timely manner. This occurred primarily during the overnight shift, and he was not cleaned up until the next morning. The resident found this experience stressful and degrading, particularly when staff stood by and urged him to hurry while using a commode or urinal. Resident #1, who had intact cognitive ability and required assistance with toileting, also reported being told to urinate in his brief. He expressed discomfort discussing the details, but it was noted that a staff member had told him he was using his call light too often and should urinate in his brief. This led the resident to request a urinary catheter to avoid bothering the night staff. Staff B, a CNA, confirmed that she had told Resident #238 it was okay to urinate in his brief if staff could not assist him in time, and she denied telling Resident #1 to urinate in his brief, although she acknowledged his frequent requests for a catheter. The facility's administrator was unaware of these incidents and stated that such behavior was intolerable. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, including accommodating their needs. However, the actions of some staff members, particularly during the overnight shift, did not align with these principles, leading to the reported deficiencies in resident care and dignity.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent falls for a resident with severe cognitive deficits. The resident, who was totally dependent on staff for hygiene and dressing and required partial assistance with transfers, had a history of attempting to get up on his own. Despite being at risk for falls due to impaired balance and increased anxiety, the resident's personal alarm was not on the chair at the time of the fall. This resulted in an unwitnessed fall in the dining room, leading to a severe left hip injury that required surgical intervention. Interviews with staff revealed that the resident was known to be easily agitated and often attempted to get up from his chair without assistance. On the evening of the fall, staff were present in the dining room but were occupied with other residents, and none witnessed the resident getting up. There was uncertainty among staff about whether the alarm was in place or functioning, and it was noted that the resident could stand up quickly, potentially rendering the alarm ineffective. Further observations indicated ongoing challenges in managing the resident's impulsiveness and fall risk. During a morning routine, a staff member failed to lock the wheels of the resident's wheelchair, which moved slightly when the resident sat down. The facility's administrator acknowledged the resident's challenges and mentioned recent medication changes that had improved his condition. However, the deficiency in supervision and adherence to care plan interventions, such as the use of motion alarms, contributed to the resident's fall and subsequent injury.
Failure to Timely Submit MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a resident's Minimum Data Set (MDS) assessment upon discharge within the required timeframe for one of the fourteen residents reviewed. The MDS assessment for Resident #10, who was discharged on 07/24/24, was completed by the Assistant Director of Nursing (ADON) on 08/01/24 but was not submitted to CMS until 10/17/2024. The Director of Nursing acknowledged issues with the MDS process, attributing the delay to the former MDS coordinator not fitting well in the position. According to the Resident Assessment Instrument (RAI) Manual Version 3.0, the discharge return not anticipated MDS must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Coon Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Park Nursing & Rehab Center Of Carroll | 15.9 mi | — | 1 | 0 |
| St Anthony Senior Services | 16 mi | — | 6 | 0 |
| The New Homestead Care Center | 16.4 mi | — | 1 | 0 |
| Friendship Home Association | 16.9 mi | — | 0 | 0 |
| Accura Healthcare Of Carroll | 17.8 mi | — | 18 | 0 |
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