Addison Heights Health And Rehabilitation Center

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, record review and interview, the facility failed to ensure bed rails were in place to assist with bed mobility. This affected one (#58) resident of three reviewed for bed rail use. The facility census was 68. Findings Include:Review of the medical record for Resident #58 revealed an admission date of 05/02/25 with diagnoses of morbid obesity, muscle weakness, and Type II Diabetes Mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/25, revealed Resident #58 had intact cognition and was able to roll to the left and right with supervision and/or touching assistance.Review of the current care plan, initiated 05/02/25 and updated 06/24/25 revealed Resident #58 had impaired functional abilities, self-care and mobility deficits. Interventions included bilateral half side rails to promote independence with bed mobility, self-positioning and transfers.Review of the Side Rail/Grab Bar Review assessments, completed 05/02/25 and 11/06/25 revealed bilateral side rails/grab bars were indicated and served as an enabler to promote independence.Review of the current physician order dated 06/04/25 revealed Resident #58 had half side rails to right and left side of bed to promote independence with bed mobility, transfers, and positioning.Observation and interview on 12/01/25 at 1:50 P.M. with Resident #58 revealed a grab bar was on the left side of his bed, but no grab bar was on the right side of his bed, which was against the wall. Resident #58 stated he was supposed to have a grab bar on both sides of the bed to assist with mobility as he received personal cares in bed and the grab bars allowed him to assist in rolling himself from side to side. Observation and interview on 12/01/25 at 1:56 P.M. with Maintenance Director (MD) #351 confirmed Resident #58's bed did not have a grab bar on the right side because of the way the mattress fit the bedframe.Interview on 12/08/25 at 12:23 P.M. with MD #351 revealed he began working in

the facility in July 2025 and since that time he had not changed Resident #58's mattress or bedframe, and had not assessed Resident #58's mattress or bedframe to assure they fit appropriately.This deficiency represents non-compliance investigated under Complaint Number 2636738.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Addison Heights Health and Rehabilitation Center

3600 Butz Rd Maumee, OH 43537

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#400, dated 11/01/25, revealed he was notified Resident #73 was trying to touch Resident #36. LPN #400 wrote he could see the side of Resident #36's brief was pulled out.Interview on 12/22/25 at 9:20 A.M. with

the Administrator revealed he was familiar with SRI #267064 and recalled the findings of the investigation were Resident #73's hand was inside Resident #36's brief, along the hip.Telephone interview on 12/22/25 at 11:37 A.M. with CNA #399 revealed she had been providing resident care to another facility resident when she came out to witness an incident between Resident #36 and Resident #73. CAN #399 stated the other staff working on the hall were the nurse who was passing medication and the other CNA who was in another resident room. CAN #399 stated she came out of the room she had been providing care in she saw Resident #36 in her wheelchair and Resident #73 kneeling beside her in the common area near the nurse's station. CNA #399 approached the two residents and saw Resident #36, seated in her wheelchair, wearing two facility-provided gowns, one open to the front underneath, and the one on top open to the back.

Resident #36 was also wearing an incontinent brief. CNA #399 stated she was able to see the right side of Resident #36's brief and saw Resident #73's fingers inside the brief at Resident #36's peri area. CNA #399 stated Resident #73's hand was coming in from the side of the brief (leg opening), not down from the top.

CNA #399 stated the brief was scrunched to the side. CNA #399 stated Resident #36's head was tilted back in a position that made it appear she enjoyed the interaction. CNA #399 further explained, based on what she saw, the placement of Resident #73's fingers positioned inside the brief at the peri area and the depth his fingers were in the brief she could tell he was touching Resident #36's, peri area. CNA #399 stated she described her observations to the Director of Nursing (DON) who came into the facility after the incident. CNA #399 stated she was directed by the DON to keep her written statement regarding the incident brief. CNA #399 confirmed the written statement in the investigation was the one she wrote.

Interview on 12/22/25 at 2:04 P.M. with the Administrator revealed he did not agree sexual abuse occurred to Resident #36. The Administrator stated the facility's investigation, which he determined to be thorough, revealed Resident #73's hand was on the side of Resident #36's brief. The Administrator noted the discrepancy between CNA #399's written statement and the telephone interview between CNA #399 and

the Surveyor. The Administrator stated the statement that was provided did not indicate sexual abuse.Review of the policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, copyright 2025, revealed the Facility shall review altercations from resident to resident as a potential situation for abuse. Additionally, staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to . c. sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing.This deficiency represents non-compliance investigated under Complaint Number 2661038, and Complaint Number 2651189.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Addison Heights Health and Rehabilitation Center

3600 Butz Rd Maumee, OH 43537

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review, staff interview, review of Self-Reported Incident #267064, and review of the facility policy, the facility failed to ensure an allegation of sexual abuse was reported timely to the State Agency.

This affected one (Resident #36) of five residents reviewed for abuse. The facility census was 68.Review of

the medical record for Resident #36 revealed an admission date of 06/27/25 with diagnoses of Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease.Review of the comprehensive, significant change Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #36 had severely impaired cognition, used a wheelchair for mobility and was dependent on staff for all activities of daily life.Review of a nursing progress note dated 11/01/25 at 10:57 P.M., and written by

the Director of Nursing, revealed Resident #36 was in her wheelchair in the lounge and another resident (Resident #73) had his hand in her brief. The residents were immediately separated and placed on 15-minute checks.Review of the facility's Self-Reported Incident (SRI) #267064 revealed it was initiated 11/02/25 at 10:11 A.M. by the Administrator. SRI #267064's Category of Allegation/Suspicion was sexual abuse.Interview on 12/22/25 at 10:56 A.M. with the Administrator confirmed he did not report the incident within two hours because he felt no abuse had occurred. Review of the policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, copyright 2025, revealed in response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility shall ensure that all alleged violations involving abuse . are reported in the proper time frame pursuant to this policy. Further review revealed the guidance: When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: . reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. This deficiency is a recite to the complaint survey completed 10/14/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Addison Heights Health and Rehabilitation Center

3600 Butz Rd Maumee, OH 43537

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

medication.Interview on 12/03/25 at 1:25 P.M. with Resident #55 revealed he recently had spinal neck surgery and had neck pain and the facility ran out of his Lyrica (pregabalin) for six doses the previous week.Interview on 12/08/25 at 1:15 P.M. with the Director of Nursing (DON) and concurrent review of Resident #55 ' s MARs dated October 2025 and November 2025 confirmed the charting indicated Resident #55 did not receive three doses of Lyrica (pregabalin) on 10/04/25, did not receive one dose on 10/05/25, did not receive three scheduled doses on 11/28/25 and did not receive three doses on 11/29/25. Review of

the policy, Administering Oral Medications, dated 10/2010, revealed staff should verify there was a physician order for the procedure of administering medications. Additionally, staff should allow the resident to swallow tablets or capsules at his or her comfortable pace.This deficiency represents non-compliance investigated under Complaint Number 2660262 and Complaint Number 2656086.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Addison Heights Health and Rehabilitation Center

3600 Butz Rd Maumee, OH 43537

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure food items were labeled with open dates and failed to ensure staff were knowledgeable regarding identifying expiration dates of packaged foods. This affected one (#16) resident identified to be on thickened liquids.

The facility census was 68.Findings Include: Review of the medical record for Resident #16 revealed an admission date of 03/01/21 with diagnoses of hemiplegia/hemiparesis, cerebral infarction, and chronic obstructive pulmonary disease. Review of the 5-day Minimum Data Set (MDS) assessment, dated 11/23/25, revealed Resident #16 had impaired cognition. Review of a physician order dated 11/19/25 and discontinued 12/02/25 revealed Resident #16 was on nectar thick liquids.Review of a current physician order dated 12/02/25 revealed Resident #16 was on nectar thickened liquids.Observations of food storage

on 12/01/25 beginning at 3:20 P.M. and concurrent interview with Dietary Manager (DM) #395, revealed a reach-in cooler with four 46-ounce cartons of nectar thickened beverages, opened, and approximately halfway consumed. DM #395 confirmed a carton of thickened water with pomegranate flavoring had the date 11/06/25 handwritten on the carton, a carton of thickened orange juice with the date 10/30/25 handwritten on the carton, a carton of thickened cranberry juice with a date 10/30/25 handwritten on the carton, and a carton of thickened milk with the date 10/09/25 handwritten on the carton. DM #395 stated

the handwritten dates were the dates the product was received into inventory. DM #395 confirmed no other date was written on the carton to identify when the product was opened. DM #395 stated only one resident

in the facility, Resident #16, was on thickened liquids and the facility did not go through the liquids very quickly. Further interview with DM #395 revealed she believed the product was safe to consume through the date stamped on the carton from the manufacturer. Continued observation of the back of each of the cartons revealed the product was to be refrigerated upon opening, and was good for seven days if refrigerated. DM #395 confirmed she did not realize the product was only good for seven days after opening.Review of the facility ' s training records, dated 10/08/25 revealed DM #395, along with all dietary staff, was educated on expired food disposal, and labeling and dating foods by the Administrator. Review of

the undated policy, Food Storage, revealed all food not in original containers will be labeled, dated and stored in appropriate containers. The policy provided no guidance regarding dating of food items with multiple servings in the original containers. This deficiency is a recite to the annual survey completed 09/15/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Addison Heights Health and Rehabilitation Center

3600 Butz Rd Maumee, OH 43537

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

slightly to take a look in the room and stated to the staff Resident #36 was still in droplet precautions.

Further observation revealed CNA #396 came to the open door and was not wearing a gown. Interview on 12/11/25 at 4:45 P.M. with CNA #336 confirmed she entered Resident #36's room without donning PPE for droplet precautions. CNA #336 stated she was rushing to provide assistance to Resident #36.Review of the policy, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, dated May 2023, revealed staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection will adhere to standard precautions and use a NIOSH-approved particulate respirator with N 95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).This deficiency represents non-compliance investigated under Complaint Number 2651189.This deficiency is a recite to the Annual Survey completed 09/15/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Addison Heights Health and Rehabilitation Center

3600 Butz Rd Maumee, OH 43537

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Based on observation, record review and interview, the facility failed to ensure mattresses and bedframes were compatible. This affected one (#58) of three residents reviewed for mattress and bed frame compatibility. The facility census was 68. Findings Include:Review of the medical record for Resident #58 revealed an admission date of 05/02/25 with diagnoses of morbid obesity, muscle weakness, and Type II Diabetes Mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/25, revealed Resident #58 had intact cognition and was able to roll to the left and right with supervision and/or touching assistance.Review of the current physician order dated 05/07/25 revealed Resident #58 required a low air loss mattress at all times. Observation and interview on 12/01/25 at 1:50 P.M. with Resident #58 revealed a grab bar was on the left side of his bed, but no grab bar was on the right side of his bed. Resident #58 stated the mattress was too big for the frame. Observation and interview on 12/01/25 at 1:56 P.M. with Maintenance Director (MD) #351 confirmed Resident #58's bed did not have a grab bar on the right side of

the bed because of the way the mattress fit the bedframe. Additionally, Resident #58's mattress overhung

the frame by approximately five inches. MD #351 confirmed Resident #58's mattress was overhanging the bed frame. MD #351 stated he was aware Resident #58's mattress was too large for the frame and was in

the process of ordering and replacing bedframes. Interview on 12/08/25 at 12:23 P.M. with MD #351 confirmed mattresses should be fully supported by the frame. This deficiency represents non-compliance investigated under Complaint Number 2636738.

Event ID:

Facility ID:

If continuation sheet