Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 a facility policy, the facility failed to provide a clean,
well-maintained, and homelike environment. This affected 10 (#7, #9, #20, #30, #31, #32, #33, #34, #35,
and #50) of 63 residents residing in the facility. The facility census was 63.
Findings include:
1. Observation on 06/30/25 at 6:45 A.M. of the room occupied by Resident #50 revealed spider webs in the
right corner of the window sill between the blind and window, the cover for the radiant heater was not
properly attached on the left side and was laying on the floor, the window sill had four pieces of missing
laminate and two additional areas of missing laminate covered with an unknown substance in an attempt to
repair them. The window sill also contained an approximately six inch long crack extending from front to
back, an area of missing paint on the wall above the bed approximately two inches long and three inches
wide. There was an approximately six inches long and 10 inches wide section of wall covered with plaster
and not painted above the resident's bed to the left of the window, two bolts sticking out approximately two
and one-half inches from the wall, and a hole in the wall above the two bolts approximately one-half inch in
diameter. In the resident's bathroom was broken drywall on each side of the shower that was approximately
two and one-half inches wide and three inches long, three gouges in the restroom wall, approximately one
and one-half inches long each. The shower was noted to be sitting loosely in the wall and the floor around
the toilet was cracked.
Interview on 06/30/25 at 7:10 A.M. with Licensed Practical Nurse (LPN) #245 verified the condition of
Resident #50's room.
2. Observation on 06/30/25 at 7:37 A.M. of the restroom shared by Resident #30 and Resident #31
revealed there was no hand soap dispenser, hand soap, or hand sanitizer available for use.
Interview on 06/30/25 at 7:41 A.M. with LPN #245 verified the condition of the restroom shared by Resident
#30 and Resident #31.
3. Observation on 06/30/25 at 10:21 A.M. of the toilet in Resident #7's restroom revealed it was leaking.
Interview on 06/30/25 at 10:23 A.M. with Housekeeper #276 verified the toilet in Resident #7's room was
leaking.
4. Observation on 07/01/25 at 8:17 A.M. of Resident #20's room revealed the corners of the wall to the right
and left of the shower were broken and missing drywall, there were three cracks in the
(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 6
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
07/01/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
floor in front of the shower approximately six inches in length, a hole in the wall above the door
approximately three-quarters of an inch in diameter, a loose electrical outlet in the wall directly above
Resident #20's bed, and a broken window sill with an approximately seven inch piece of laminate missing.
Interview on 07/01/25 at 8:24 A.M. with LPN #215 verified the condition of Resident #20's room.
Residents Affected - Some
5. Observation on 07/01/25 at 8:25 A.M. of Resident #34's room revealed an approximate 12-inch long
section of paint that was peeling and bubbled from under the window sill and three holes in the restroom
door that are each approximately two-inched in diameter.
Interview on 07/01/25 at 8:28 A.M. with Certified Nurse Aide (CNA) #278 verified the condition of Resident
#34's room.
6. Observation on 07/01/25 at 8:29 A.M. of Resident #35's room revealed peeling paint on walls, an area of
unidentified greenish-black staining on the wall approximately two feet long by three feet wide on the wall, a
loose electrical outlet by the head of the resident's bed, and two holes approximately two inches in
diameter in the door to resident's restroom.
Interview on 07/01/25 at 8:31 A.M. with CNA #271 verified the condition of Resident #35's room.
7. Observation on 07/01/25 at 8:33 A.M. in Resident #9's room revealed a loose electrical outlet to the left
of the resident bed, three holes in the door going to the resident's restroom, three cracks in the tile in front
of the shower, and no shower head in the resident's shower.
Interview on 07/01/25 at 8:37 A.M. with CNA #271 verified the condition of Resident #9's room and
restroom.
8. Observation on 07/01/25 at 8:38 A.M. of the memory care (MC) unit shower room revealed one of three
showers was operational and able to be used by residents. The first shower was operational and able to be
used for resident care. Further observation revealed the second shower had a broken shower head and the
third shower was not functioning correctly.
Interview on 07/01/25 at 8:49 A.M. with LPN # 215 verified the condition of the MC unit shower room.
9. Observation on 07/01/25 at 8:39 A.M. of Resident #32's room and restroom revealed an approximately
eight-inch long by 18-inch wide section of wall behind and to the left of the bed was damaged with peeling
paint and exposed drywall. There were generalized areas of damage to the walls throughout the resident
room, an unidentified brown substance on the wall, approximately two-inches in diameter, peeling rubber
baseboards, a non-functional light in the restroom, damage to the wall corners on both sides of the shower,
spider webs in the upper left corner of the restroom, spider webs in the exhaust fan grate above the toilet,
an unidentified green substance on the restroom ceiling, and a missing shower curtain.
Interview on 07/01/25 at 8:49 with LPN #245 verified the condition of Resident #32's room and restroom.
10. Observation on 07/01/25 at 8:46 A.M. of Resident #33's restroom revealed a missing cover on the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366041
If continuation sheet
Page 2 of 6
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
07/01/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
radiant heater, non-functioning restroom lights, damage to the wall on both sides of the shower, and a
missing shower curtain.
Interview on 07/01/25 at 8:49 A.M. with LPN #245 verified the condition of Resident #32's restroom.
Interview on 07/01/25 at 8:58 A.M. with the Administrator verified the observations of the conditions
observed in the rooms and restrooms for 10 (#7, #9, #20, #30, #31, #32, #33, #34, #35, and #50) residents
on the MC unit.
Review of the facility policy titled, Homelike Environment, dated February 2021, revealed residents are
provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal
belongings to the extent possible.
This deficiency represents non-compliance investigated under Complaint Number OH00166848 and
Complaint Number OH00165912.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366041
If continuation sheet
Page 3 of 6
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
07/01/2025
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based
medical record review, review of care conference documentation, staff interview, and review of a facility
policy, the facility failed to ensure care conferences were held for residents as required. This affected one
(#1) of three residents reviewed for timely care planning conferences. The facility census was 63.
Findings include:
Review of the medical record for Resident #1 revealed an admission date of 01/16/25 with diagnoses
including encephalitis, dementia, abnormal findings of the lung field, latent tuberculosis, hypokalemia, and
restlessness and agitation. Further review revealed Resident #1 had a discharge date of 06/05/25.
Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief
Interview of Mental Status (BIMS) score of 03, indicating Resident #1 was cognitively impaired. Further
review of the MDS assessment for Resident #1 revealed she required assistance with all functional abilities.
Review of the facility supplied care conference documentation for Resident #1 revealed only one care
conference was held for the resident during her admission on [DATE].
Interview on 06/30/25 at 9:29 A.M. with Social Services Designee (SSD) #274 revealed she had been in
her position since 05/02/25, and the previous SSD left the position before she began. SSD #274 stated she
was trying to catch up on resident care conferences, and stated care conferences are held at admission,
quarterly, if a resident or family requests an additional care conference, with a change in condition, or as
needed.
Interview on 07/01/25 at 8:58 A.M. with the Administrator verified the facility only held one care conference
for Resident #1 during her admission. The Administrator stated residents are required to have care
conferences at admission, quarterly, and with a significant change in condition.
Review of the undated facility policy titled, IDT Team Members Participation in Resident Care Conference,
revealed care conferences for long term care residents shall occur on a regular basis (i.e. initial, quarterly,
annual, significant change in status, and as needed).
This deficiency represents non-compliance investigated under Complaint Number OH00166848.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366041
If continuation sheet
Page 4 of 6
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
07/01/2025
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and review of a facility clinical protocol, the facility failed
to ensure interventions to prevent skin breakdown were implemented as ordered by the physician. This
affected one (#3) of three residents reviewed for skin breakdown and pressure relieving interventions in a
facility census of 63.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #3 revealed the resident admitted to the facility on [DATE] with
diagnoses including, multiple sclerosis, coronary artery disease, hypertension, major depressive disorder,
metabolic encephalopathy, muscle weakness, and dementia.
Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was
assessed with moderately impaired cognition, dependent on staff for the completion of activities of daily
living including transfer and bed mobility, noted as incontinent of bowel and bladder, and was at risk for
pressure ulcer development with no current skin breakdown.
Review of Resident #3's physician orders revealed on 01/30/22 the physician initiated the application of a
pressure reducing cushion to the resident's wheelchair at all times with instructions to check placement
every shift and replace as needed. On 07/12/23 the physician implemented offloading boots to bilateral
lower extremities at all times
Review of a nursing plan of care dated 01/24/24 revealed the plan of care was was revised to address
Resident #3's risk for skin breakdown related to fragile skin, decreased mobility, incontinence, and history
of skin breakdown. Interventions included to administer treatments as ordered, educate the
resident/family/caregivers of causative factors and measures to prevent skin injury, encourage the resident
to lay down between meals, follow facility protocols for treatment of injury, Roho cushion (a type of
wheelchair cushion designed to prevent and promote healing of pressure sores) to wheelchair, weekly skin
assessment, and monitor/report/document any adverse findings.
Review of Resident #3's medical record revealed on 06/06/25 a pressure ulcer risk evaluation (Braden)
assessed Resident #3 at moderate risk for skin breakdown with a score of 14.
Review of a wound assessment on 06/10/25 documented Resident #3 with a stage III pressure ulcer
(full-thickness skin loss) to the coccyx was resolved (healed).
Observations on 6/24/26 at 1:50 P.M. noted Resident #3 seated in a reclining geriatric chair (geri-chair) with
no cushion applied to the seat and bilateral feet were resting on the footrest. There were no off-loading
boots in place.
Observation on 06/25/25 at 9:58 A.M. noted Resident #3 up in a geri-chair, reclined with the feet elevated.
There was no foot elevation, off loading boots, or pressure reliving cushion in place.
On 06/25/25 at 10:00 A.M. interview with Certified Nurse Aide (CNA) #231 verified Resident #3's pressure
relieving devices were not in place and were unable to be located inside Resident #3's room. Review of
electronic CNA resident specific information with CNA #231 lacked information instructing CNAs to utilize
off-loading boots or a pressure relieving cushion for Resident #3.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366041
If continuation sheet
Page 5 of 6
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
07/01/2025
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)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
At 10:02 A.M. observation with nursing supervisor Licensed Practical Nurse (LPN) #215 verified the
devices were ordered by the physician and were not in place as indicated for Resident #3. LPN #215
confirmed Resident #3 had recently healed a pressure ulcer to his coccyx.
Review of a facility pressure ulcers/skin breakdown clinical protocol, revised April 2018, revealed the
physician will order pertinent wound treatments, including pressure reduction surfaces.
This deficiency represents non-compliance investigated under Complaint Number OH00166848 and
Complaint Number OH00165912.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366041
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
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.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the July 1, 2025 survey of ADDISON HEIGHTS HEALTH AND REHABILITATION CENTER?
This was a inspection survey of ADDISON HEIGHTS HEALTH AND REHABILITATION CENTER on July 1, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ADDISON HEIGHTS HEALTH AND REHABILITATION CENTER on July 1, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.