Health inspection·May 1, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure residents were provided a comfortable and homelike environment. This affected three (#18, #27, #49) of six resident rooms observed and had the potential to affected all 26 residents (#39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, and #64) who resided in the memory care unit in a facility census of 64. Findings Include: 1. Observation on 04/30/25 at 6:50 A.M. revealed Resident #53 in the common area of the memory care (MC) unit seated in a wheelchair wearing a heavy winter coat with the hood pulled over her head. Concurrent observation revealed Resident #41 seated in a wheelchair wrapped in a blanket. Interview on 04/30/25 at 7:00 A.M. with Resident #53 verified she was wearing a coat due to the cold air temperature of the MC unit. Resident #53 indicated it was always cold on the MC unit. Interview on 04/30/25 at 7:05 A.M. with Resident #41 verified he was wrapped due to the air temperature of the MC unit. Resident #41 stated it was too cold on the MC unit. Observation on 04/30/25 at 7:06 A.M. revealed the thermostat that controlled the air temperature in MC unit, located in the corridor of the MC unit, was set to 69 degrees (°) Fahrenheit (F). Interview on 04/30/25 at 7:07 A.M. with Registered Nurse (RN) #234 verified Resident #41 was seated in a wheelchair wrapped in a blanket and Resident #54 was seated in a wheelchair wearing a heavy winter coat with the hood pulled over her head. RN #234 verified the thermostat located in the corridor of the MC unit controlled the air temperature in the MC unit. Further interview with RN #234 verified the thermostat was set to 69°F. At this time RN #234 change the temperature setting on the thermostat from 69°F to 74°F. As RN #234 changed to temperature setting, RN #234 stated, It's freezing. I'm sorry. Review of the facility policy titled, Homelike Environment, with a revision date of February 2021, revealed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable and safe temperatures (71°F to 81°F). 2. Review of Resident #18's medical record revealed an admission date of 04/04/25 with diagnoses that included infection and inflammatory reaction due to unspecified internal joint prosthesis, Page 1 of 4 366041 366041 05/01/2025 Addison Heights Health and Rehabilitation Center 3600 Butz Rd Maumee, OH 43537

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some presence of unspecified artificial knee joint, hypertension, hypothyroidism, chest pain, type two diabetes mellitus, cardiomyopathy, intraductal carcinoma in situ of the right breast, morbid obesity due to excess calories, and periprosthetic fracture around other internal prosthetic joint. Review of the admission Minimum Data Set (MDS) assessment, dated 04/11/25, for Resident #18 revealed the resident had intact cognition. Observation on 04/29/25 at 12:43 P.M. of the wall behind the bed in Resident #18's room revealed an approximate three feet long by one foot wide area of damaged. Interview at the time of observation with Resident #18 revealed the damage to the wall was present since her admission on [DATE]. Interview on 04/29/25 at 12:51 P.M. with Licensed Practical Nurse (LPN) # 210 verified the wall behind the bed in Resident #18's room contained an approximate three feet long long by one foot wide area of damage. 3. Observation on 04/29/25 at 10:32 A.M. of Resident #27's bedroom revealed a large area of peeling paint behind the bed Interview on 04/29/25 at 10:33 A.M. with Certified Nurse Aide (CNA) #213 verified a large area of peeling paint in behind Resident #27's bed. 4. Review of Resident #49's medical record revealed an admission date of 01/01/25 with diagnoses of encephalitis and encephalomyelitis, unspecified dementia, other nonspecific abnormal finding of the lung field, latent tuberculosis, hypokalemia, restlessness and agitation, personal history of malignant neoplasm of the breast, acquired absence of bilateral breasts and nipples, anemia, wedge compression fracture of unspecified lumbar vertebra, and pneumonia. Review of the most recent quarterly MDS assessment, dated 04/09/25 for Resident #49 revealed the resident had severely impaired cognition. Observation on 04/29/25 at 10:03 A.M. of Resident #49's room revealed peeling paint on the wall behind her bed and a window sill with multiple broken areas and multiple areas of chipping plastic laminate covering. Further observation of Resident #49's room revealed an approximate 24-inch crack at the base of the toilet and the toilet was not properly secured to the floor and moved when sat upon. Continued observation of Resident #49's restroom revealed the base of the wall at the exit of the shower was missing pieces of drywall. Interview on 04/30/25 at 10:05 A.M. with CNA #225 verified the above findings in Resident #49's room and restroom. Review of the facility policy titled, Homelike Environment, with a revision date of February 2021, revealed residents are provided with a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Master Complaint Number OH00165139 and OH00164080. 366041 Page 2 of 4 366041 05/01/2025 Addison Heights Health and Rehabilitation Center 3600 Butz Rd Maumee, OH 43537

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, staff interview, review of Safety Data Sheets (SDS) documents, review of product labels, and policy review, the facility failed to ensure chemicals were stored in a safe and secure manner. This had the potential to affect four (#17, #21, #23, and #27) of four residents identified by the facility as being cognitively impaired and independently mobile who resided outside of the memory care (MC) unit. The facility census was 64. Findings Include: Observation on 04/29/25 at 12:53 P.M. of the linen cart located by Resident #12 and Resident #22's room revealed one canister of Sani-Cloth germicidal disposable wipes with a purple colored top and one canister of Sani-Cloth bleach germicidal disposable wipes with an orange colored top. Further observation revealed both canisters were open and accessible to residents. Review of the product label for the Sani-Cloth germicidal disposable wipes revealed they are not skin or baby wipes and to keep out of reach of children. The product label indicated when using the product, wear disposable protective gloves, protective gowns, masks, and eye coverings. The warning label indicated the product can cause substantial but temporary eye damage and to not get it in the eyes or on clothing and avoid contact with the skin. Users are to wash the hands thoroughly with soap and water after handling and before eating, drinking, or chewing gum, using tobacco, or using restroom. The label further revealed the product was hazardous to humans and domestic animals. Review of the facility provided SDS for the Sani-Cloth germicidal disposable wipes revealed the product may be harmful if swallowed and may be fatal if inhaled. Review of the product label for the Sani-Cloth bleach germicidal disposable wipes revealed they are not skin or baby wipe and to keep out of reach of children. The product label revealed when using the product to wear appropriate barrier protection such as gloves, gowns, masks, and eye covering and indicated the product contained bleach. The label further revealed the product caused moderate eye irritation and users should avoid contact with the eyes or clothing. Users should wash the hands thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco, or using the toilet. Review of the facility provided SDS for the Sani-Cloth bleach germicidal disposable wipes revealed contact with the liquid may cause slight eye irritation. Interview on 04/29/25 at 12:55 P.M. with Licensed Practical Nurse (LPN) #221 verified one canister of Sani-Cloth germicidal disposable wipes and one canister of Sani-Cloth bleach germicidal disposable wipes were both open, stored on the blue linen cart by Resident #12 and Resident #22's room, and accessible to residents. LPN #221 further revealed chemicals were supposed to be stored behind the nurses' station in a locked room or in a locked compartment on the medication administration cart. Review of the facility policy titled, Safety and Supervision of Residents, with a revision date of July 2017, revealed the facility strived to make the environment as free from accident hazards as possible. Review of the facility policy titled, Homelike Environment, with a revision date of February 2021, 366041 Page 3 of 4 366041 05/01/2025 Addison Heights Health and Rehabilitation Center 3600 Butz Rd Maumee, OH 43537

F 0689 revealed residents are provided with a safe, clean, comfortable and homelike environment. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00165139. Residents Affected - Some 366041 Page 4 of 4