Addison Heights: Wound Care Failures Leave Resident Untreated - OH
The resident, identified in inspection records as Resident 45, told inspectors during an interview on September 9 that he wanted his compression stockings applied but that staff had not done so. He said he had asked for a new mattress multiple times. No replacement had arrived.
Two days later, a wound specialist weighed in. A physician assistant from a wound care and hyperbaric center, reached by phone on September 11, told inspectors that Resident 45's wounds were healing slowly and that the absence of a functioning air mattress, combined with staff not elevating his lower extremities, could be contributing to that delay.
The same morning, inspectors walked into Resident 45's room and found a new air mattress had finally been placed on his bed and was running. His compression stockings were on. His offloading boots were not.
A licensed practical nurse confirmed it on the spot. The boots were not in place.
The boots had their own separate problem. When inspectors examined the room, they found a pair of large fleece-lined boots and a single black boot tangled together. Resident 45 said the fleece boots were not his. A nursing assistant, identified as CNA 402, said she did not know which boots belonged to which resident.
The mattress Resident 45 had been lying on was equipped with a pressure monitoring system that was supposed to alert staff when something was wrong. According to the manufacturer's manual the facility provided to inspectors, the Emerald Selectis air mattress model 61057 has a visible indicator, either yellow or red, that warns when pressure drops below a set level. After two and a half minutes of low pressure, an audible alarm activates. There is also a mute button.
The inspection report does not say how long the alarm had been silenced, or whether it had sounded at all. It does not say who, if anyone, had checked the mattress in the days or weeks before inspectors arrived. What it says is that a man with wounds that were slow to heal had been asking for a working mattress and had not received one, and that a clinician who treated those wounds connected the missing equipment directly to his condition.
This complaint investigation, completed September 15, 2025, was tied to three separate complaints filed against the facility, in addition to the master complaint number under which the deficiency was recorded. The inspection covered care provided at the facility's address on Butz Road in Maumee.
The wound care policy on file at Addison Heights, last revised in October 2010, instructs staff to verify a physician's order exists for wound care procedures and to review the resident's care plan for special needs before proceeding. Whether staff reviewed Resident 45's care plan before leaving him without his offloading boots or compression stockings on the mornings inspectors were not present, the report does not say.
What the wound specialist said was direct: the lack of a functioning air mattress and the failure to elevate his legs could be contributing to why his wounds were not healing.
When inspectors arrived on September 11, the mattress had just been replaced. The stockings were on. The boots, entwined with another resident's boot on the floor, were not.
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.
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 22, 2026 · Our methodology
ADDISON HEIGHTS HEALTH AND REHABILITATION CENTER in MAUMEE, OH was cited for violations during a health inspection on September 15, 2025.
He said he had asked for a new mattress multiple times.
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.