Addison Heights Rehab: RN Staffing Failures - OH
The facility's census hit 61 on September 4, 5, and 6 of 2025. The threshold that triggers a requirement for a registered nurse on duty for eight consecutive hours each day is 60 residents. On each of those three days, the only registered nurse listed anywhere in the facility's staffing documentation was the Director of Nursing.
Nobody else.
Federal inspectors launched the review under a complaint investigation. When they sat down on September 11 with the facility's scheduling coordinator, identified in inspection records only as SC #466, the coordinator confirmed both facts without dispute: no additional registered nurse had been scheduled on any of the three days, and the census had exceeded 60 on each of them.
The violation affected all 60 residents then living at the facility, according to the inspection report, which cited potential for harm across the entire resident population.
What that looks like in practice is a building where, across a full 24-hour period, the clinical oversight a registered nurse provides — assessing residents, catching deteriorating conditions, making judgment calls that licensed practical nurses and aides are not trained or authorized to make — rested entirely on one person who also carried the administrative and supervisory demands of running the nursing department.
The Director of Nursing is not a shift position. The role carries facility-wide responsibility for care planning, staff management, regulatory compliance, and a range of other functions that exist alongside, not instead of, bedside clinical oversight. When a facility's census tips past 60, the expectation is that a second registered nurse covers the floor so that clinical oversight doesn't collapse into a single set of hands.
At Addison Heights, it did. For three days running.
The inspection report does not describe any specific resident harmed during those three days. The cited level of harm is "minimal harm or potential for actual harm," the lower end of the federal harm scale. But the potential-for-harm designation covers all 61 residents who were in the building while the staffing gap existed, and the gap wasn't a scheduling accident on one overnight shift. It held across the better part of a week.
The scheduling coordinator did not offer an explanation for why no additional registered nurse had been placed on the schedule. The inspection report records only the confirmation of the facts, not any account of why the facility was operating this way or whether it had tried and failed to fill the shifts, or simply hadn't tried.
Addison Heights sits at 3600 Butz Road in Maumee, a suburb just southwest of Toledo. The complaint that triggered the inspection was filed under complaint number 2608577. Inspectors completed their review on September 15, 2025, and the deficiency was documented on a form printed months later, in April 2026.
The staffing requirement at issue is not a new or ambiguous rule. It has been part of federal nursing home regulations for decades, and the trigger point — 60 residents — is explicit. A facility that exceeds that number is required to schedule a registered nurse for eight consecutive hours every day. Addison Heights exceeded it. The schedule showed no one.
Whether anyone at the facility noticed the census crossing the threshold on September 4 and made a decision about staffing, or whether the crossing went untracked, the inspection report doesn't say. What it says is that when the scheduling coordinator reviewed the records with inspectors, the gap was there in the documentation, plain and confirmed.
Sixty-one residents. Three days. One registered nurse listed for the entire building, and she was the Director of Nursing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Addison Heights Health and Rehabilitation Center from 2025-09-15 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 28, 2026 · Our methodology
ADDISON HEIGHTS HEALTH AND REHABILITATION CENTER in MAUMEE, OH was cited for violations during a health inspection on September 15, 2025.
The facility's census hit 61 on September 4, 5, and 6 of 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.