Inspection·January 22, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and policy review, the facility failed to ensure an accurate system for the dispensing, administration, reconciliation and destruction of controlled substances. The facility identified 34 residents receiving controlled pain medications. The facility census was 73. Findings include:Review of the medical record for Resident #161 revealed an admission date of 10/22/25. Diagnoses included malignant carcinoid tumor of the bronchus and lung, chronic obstructive pulmonary disease, malignant neoplasm of the liver, and low back pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was independent for all activities of daily living. The resident had frequent pain.Review of physician orders dated 12/29/25 revealed an order for Oxycodone 30 milligrams (mg), one tablet by mouth every four hours as needed for pain, discontinue when new medication arrives for 20 mg.Review of the physician orders dated 12/30/25 revealed an order for Oxycodone 20 mg, two tablets by mouth three times a day for pain and give two tablets by mouth every four hours as needed for pain. The medication orders for the scheduled medication and as needed medication were on the same medication card. Review of a pharmacy invoice packing slip dated 12/30/25 revealed the facility had received three cards of Oxycodone 20 mg. Each card contained 30 tablets. Review of the Medication Administration Records (MAR) dated 12/30/25 through 01/02/26 revealed the resident had received 26 tablets of Oxycodone. Further review of the MAR from 01/09/26 at 9:00 A.M. through 01/11/26 at 5:12 P.M. revealed the resident was administered 28 tablets of Oxycodone. Review of the controlled substance medication monitoring/control records from 12/09/25 through 01/20/26 revealed there were no control records in the resident's medical record for the Oxycodone administered 12/30/25 through 01/02/26 and from 01/09/26 through 01/11/26. Review of the controlled substance medication monitoring/control records dated 12/25/25 through 01/03/26 revealed on 01/03/26 two tablets of the discontinued Oxycodone 30 mg were removed from the medication card at 3:00 A.M. Review of the MAR and nurse's notes revealed no documentation the medication was administered, disposed of or wasted. Further review of the MAR dated 01/04/26 revealed the resident was administered two tablets of Oxycodone 20 mg at 2:56 A.M. Review of the control record for the Oxycodone revealed the medication had not been removed from the medication card to administer on 01/04/26. Review of the nurse's notes for 01/04/26 revealed no documentation why the medication was documented as administered when it had not been removed from the medication card. Review of the control record revealed the Oxycodone medication count on 01/03/26 was 18 tablets at 9:00 P.M. and 16 tablets on 01/04/26 at 9:00 A.M. when the medication was administered again. Review of the control substance record of disposal dated 01/13/26 revealed nine Oxycodone 30 mg tablets received on 12/17/25 had been destroyed for Resident #161. Review of the Oxycodone control record dated 12/25/25 through 01/03/26 revealed there were only four tablets of Oxycodone remaining. Further review of the control record revealed a crossed out entry for the destruction of nine (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 01/22/2026 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)