Inspection·December 19, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, staff interview, and review of facility policy, the facility failed to ensure facility air temperatures were maintained at a comfortable and acceptable level. This affected 18 (#2, #3, #5, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29) of 68 residents residing in the facility observed for air temperatures. The facility census was 68. Findings include: Observation during tour of the facility on 12/18/24 between 10:30 A.M. and 10:51 A.M. with Maintenance Director (MD) #1 noted the facility heating ventilation and air conditioning was provided by forced air and multiple room furnaces. Each room was equipped with an electric radiant heat baseboard local control unit. Observation of ambient air temperature readings obtained in the memory care unit common corridor which contained eight (#15, #16, #17, #18, #19, #20, #21, and #22) resident's rooms was 68.7 degrees Fahrenheit (F). Located outside of Resident #15's room was a digital furnace thermostat on the wall of the common corridor. The digital reading on the thermostat was 75 degrees F; however, ambient air temperature in the same location was recorded at 68.7 degrees F when obtained. Observation in another memory care common corridor which contained nine (#3, #5, #23, #24, #25, #26, #27, #28, and #29) resident's rooms revealed an ambient air temperature reading of 66.9 degrees F. Observation in the memory care unit common shower noted the room was equipped with three forced air supply vents installed in the ceiling and two electric radiant heat wall heaters equipped with local controls. Temperature readings inside the shower room were recorded at 65.3 degrees F and the temperature reading of air movement from the supply vents was 66.0 degrees F. The two electric radiant heat wall heaters were not operational and lacked control knobs to energize the heaters. Further observation of air temperatures on 12/18/24 between 10:30 A.M. and 10:51 A.M. with MD #1 revealed the air temperature in Resident #15's room was 67.1 degrees F, the air temperature in Resident #18's room was 69.6 degrees F, the air temperature in Resident #21's room was 70.1 degrees F, the air temperature in Resident #23's room was 66.9 degrees F, the air temperature in Resident #3's room was 65.3 degrees F, and the air temperature in Resident #5 and Resident #27's room was 67.6 degrees F. Observation of the air temperature in Resident #2's room, located off the memory care unit, revealed an ambient air temperature of 69.4 degrees F. Interview with Certified Nurse Aide (CNA) #200 and CNA #201 on 12/18/24 at 11:02 A.M. revealed they were assigned to the residents residing on the memory care unit. CNA #200 and CNA #201 confirmed all residents on the unit received showers and associated bathing inside the common shower. Both CNA #200 and CNA #201 verified the temperatures were cool while providing resident bathing and they had no access to make heat adjustments. (continued on next page) 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 Page 1 of 2 Event ID: 366041 Printed: 05/15/2026 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 366041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 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)