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, (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 4 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 05/01/2025 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)