Thomas Rest Haven

Inspectors wroteBased 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. *Audits of transfers and ambulation to ensure gait belt use when required. *Supervisory observations by nursing leadership. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to use universal infection control measures (hand hygiene), and Enhanced Barrier Precautions (EBP) during catheter cares/wound cares for 5 of 5 residents reviewed for infection control (Residents #1, #3, #10, and #26). The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to acquire a physician's signature on an Advance Directive in 1 of 3 residents (Resident #29) reviewed. The facility reported a census of 31 residents. Findings Includes: Resident #29's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Resident #29's MDS documented active diagnoses: [...]

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to ensure that staff contacted the physician when a resident had a change in status for 1 of 2 residents reviewed. Resident #31 had many falls during his stay and the chart lacked documentation of physician notification. The resident was found to have a bruised, swollen hand and staff failed to contact the doctor for direction or orders. The facility reported a census of 31 residents.

Inspectors wroteBased on personnel file review, staff interviews, and policy review, the facility failed to ensure that current background checks had been completed for 1 of 4 staff reviewed. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview, and policy review the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 2 of 3 residents (Residents #3, and #32) reviewed. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, family interview, staff interview and policy review, the facility failed to provide timely and accurate assessment and interventions for 1 of 2 residents reviewed (Resident #31.) Resident #31 had many falls and the staff failed to complete skin assessments with measurements and failed to document and monitor injuries. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, and policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 31 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 3 of 4 residents reviewed (Residents #2, #3, and #10) requiring the use of oxygen. The facility reported a census of 31 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were treated with dignity and respect for 2 of 13 residents reviewed. Resident's #238 and #1 reported that a staff member instructed them to urinate in their adult briefs if/when they couldn't assist them to the restroom in a timely manner. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate nursing supervision to prevent falls for 1 of 4 residents reviewed (Resident #24). Resident #24 had a fall that caused injury after he got up from the chair without assistance. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that staff were aware of the date that a stock supplement had been opened before administering it to a resident for 1 of 4 residents reviewed (Resident #17). The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interview, facility policy review, and the Resident Assessment Instrument (RAI) Manual, and policy review, the facility failed to complete and transmit a resident Minimum Data Set assessment upon a resident's discharge within the required time-frame for one of fourteen residents reviewed (Resident #10). The facility reported a census of 37 residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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. The facility reported a census of 33 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders for 2 of 13 residents reviewed (Resident #14 and #31). Following a procedure to remove ingrown toe nails, the podiatrist gave new orders for care of Resident #14's feet. During an interview and observation three days after the appointment revealed that the facility failed to complete the orders for Resident #14. The facility failed to apply Resident #31's ordered edema wear (special socks used to treat swelling) as ordered by the physician.

Inspectors wroteBased on personnel file review, facility policy review, and staff interview the facility failed to provide the recertification dependent adult abuse training within 3 years for 1 of 5 employee reviewed (Staff E, Certified Nurse Aide CNA). The facility reported a census of 33 residents.