Addison Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure water temperatures were appropriate. This affected one (Resident #25) of three reviewed for environmental concerns and had the potential to affect all 54 residents in the facility.Findings include:Review of the medical record for Resident #25 revealed an admission date of 07/13/23. Diagnoses included kidney disease, depression, glaucoma, hypertension and irritable bowel syndrome.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. He required set-up help for eating and oral care and was dependent on staff for toileting, showering, dressing and personal hygiene.Interview on 03/16/26 at 9:08 A.M. with Resident #25 revealed the water in his bathroom sink was never hot.Observation on 03/18/26 at 7:29 A.M. of the sink in Resident #25's room revealed the water reached a temperature of 80 degrees Fahrenheit (F).Interview on 03/18/26 at 9:53 A.M. with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were comprehensive. This affected three Residents (Residents #2, #11 and #50) of 18 reviewed for care plans and had the potential to affect all 54 residents in the facility. Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 02/20/26. Diagnoses included cerebral infarction, diabetes, dementia, heart disease, depression and kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. He required supervision for eating, substantial to maximum assistance for oral care, personal care and showering and was dependent on staff for toileting. Review of the physician's orders for March 2026 revealed an order for Trazadone (an antidepressant) 50 milligrams (mg) at bedtime. The order began on 03/02/26. There was also an order to monitor for side effects of antidepressants including stiffness of neck, dry mouth, sweating or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to provide transportation to medical appointments as needed for Resident #11. This affected one resident (#11) of one resident who was investigated for transportation needs. The facility census was 54.Findings include:Review of Resident #11's medical record revealed an admission date of 01/27/26 with diagnoses including nondisplaced fracture of lateral malleolus of left fibula, unspecified injury of right quadriceps muscle, fascia and tendon, autoimmune thyroiditis, chronic obstructive pulmonary disease and hypertension.Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Resident #11 required supervision with toileting, moderate assistance with bathing, supervision with upper extremity dressing, moderate assistance with lower extremity dressing and supervision with personal hygiene.Review of physician's orders for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure pressure reducing interventions were in place as ordered by the physician for Resident #50. This affected one resident (#50) of three residents reviewed for pressure ulcers and had the potential to affect five additional residents (#4, #5, #16, #62 and #64) identified by the facility with pressure ulcers. The facility census was 54. Findings include:Review of the medical record for Resident #50 revealed an admission date of 02/06/26. Diagnoses included sepsis, respiratory failure, heart failure, kidney failure and malnutrition.Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. He required set-up help for eating, partial to moderate assistance for oral and personal hygiene, substantial to maximum assistance for showering and was dependent on staff for toileting. He had one Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and review of the facility policy, the facility failed to ensure that Resident #7's therapy recommendation for built up utensils at all meals was properly assessed, that a corresponding physician's order was obtained, and that the intervention was incorporated into the care plan. This affected one resident (#7) of one resident reviewed for assistive devices and had the potential to affect three additional residents (#16, #20, and #48) identified by the facility as utilizing assistive devices. The facility census was 54.Findings include:Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus with diabetic polyneuropathy and atherosclerotic heart disease of native coronary artery without angina pectoris.Review of the therapist's order dated 04/21/25 revealed Resident #7 was to have black built-up utensils for all meals.Review of the Minimum Data Set (MDS) assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and review of facility policies, the facility failed to provide wound care to Resident #16 in a manner to prevent infection. This affected one resident (#16) of two residents observed for wound care. The facility census was 54.Findings include:Review of the medical record for Resident #16 revealed an admission date of 09/03/25 and a readmission date of 01/23/26. Diagnoses included acute respiratory failure with hypoxia, pressure ulcer of the sacral region Stage IV (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed; often includes undermining and tunneling), and type two diabetes mellitus.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe cognitive impairment. Resident #16 required extensive assistance for all activities of daily living.Review of the physician's order dated 03/12/26 revealed an order to clean the coccyx wound with normal saline…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of the facility Self-Reported Incident (SRI) and related facility investigation, and policy review, the facility did not ensure Residents #2, #4, #23, and #35 were free from the misappropriation of their controlled substance narcotic pain medication. This affected four residents (Resident #2, #4, #23, and #35) out of four residents reviewed for misappropriation of property. This had the potential to affect 14 residents (#1, #2, #4, #8, #11, #21, #23, #26, #32, #33, #35, #36, #39, and #153) the facility identified as residing on the A unit and had orders for controlled substances. The facility census was 48. Findings included: 1. Review of the SRI dated 01/03/25 revealed the facility reported an incident of misappropriation. The report revealed Licensed Practical Nurse (LPN) #332 arrived at the facility on 01/03/25 at 3:00 A.M. and was unable to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of QSO-24-08-NH memorandum, and review of facility policy revealed the facility did not utilize enhance barrier precautions (EBP) when indicated for Residents #17 during the administration of medication through his percutaneous endoscopic gastrostomy (PEG) tube. This affected one Resident (#17) out of two residents observed for EBP. The facility identified 11 Residents (#3, #4, #11, #17, #22, #28, #36, #42, #38, #39, #153) who required EBP. The facility census was 48. Findings include: Review of the medical record for Resident #17 revealed an admission date of 11/23/20 and diagnoses including spastic quadriplegic cerebral palsy, convulsions, dysphagia, and adult failure to thrive. Review of the care plan last revised 05/20/21 revealed Resident #17 required a PEG tube (medical device used to provide nutrition and hydration directly into the stomach) feeding related to dysphagia. Interventions included provide tube feeding per medical provider orders,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review and policy review, the facility failed to implement the abuse policy and procedure after receipt of an allegation of staff to resident verbal abuse for Resident #53. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52. Findings include: Review of the medical record for Resident #53 revealed an admission date of 08/09/23 and discharge date of 11/17/23. Diagnoses included anoxic brain damage, spastic hemiplegia, major depressive disorder, anxiety disorder, heart failure, and need for assistance with personal care. Review of the Quarterly and State Optional Minimum Data Set (MDS) assessments dated 11/16/23 revealed Resident #53 had moderate cognitive impairment, and required extensive two staff assistance for bed mobility, transfers, and toileting. Resident #53 was frequently incontinent of bowel and bladder. Review of the care plan dated 08/09/23 revealed Resident #53 had a neurologic disorder and impaired cognitive function related to traumatic brain injury with spastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review and policy review, the facility failed to report an allegation of staff-to-resident verbal abuse for Resident #53 to the state agency. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52. Findings include: Review of the medical record for Resident #53 revealed an admission date of 08/09/23 and discharge date of 11/17/23. Diagnoses included anoxic brain damage, spastic hemiplegia, major depressive disorder, anxiety disorder, heart failure, and need for assistance with personal care. Review of the Quarterly and State Optional Minimum Data Set (MDS) assessments dated 11/16/23 revealed Resident #53 had moderate cognitive impairment, and required extensive two staff assistance for bed mobility, transfers, and toileting. Resident #53 was frequently incontinent of bowel and bladder. Review of the care plan dated 08/09/23 revealed Resident #53 had a neurologic disorder and impaired cognitive function related to traumatic brain injury with spastic hemiplegia and convulsions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #25 had bilateral hand splints as ordered. This affected one resident (Resident #25) out of one resident reviewed for splints. Findings included: Review of medical record for Resident #25 revealed an admission date of 11/23/20 and diagnoses included spastic quadriplegic, cerebral palsy, adult failure to thrive, and muscle weakness. Review of care plan dated 05/11/21 revealed Resident #25 had an activities of daily living self- care performance deficit that required assistance related to spastic quadriplegic cerebral palsy. Interventions included total assistance of two staff with bed mobility, transfers, and dressing. There was no documentation in the care plan regarding contracture's to his bilateral hands and bilateral splinting carrots (a fabric splint device in the shape of a carrot to prevent contracture's to hand) to his hands were to be implemented. Review of physician order dated 03/29/22 revealed Resident #25 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the pharmacy delivered medications in a timely manner to ensure Resident #44 and Resident #99 received intravenous antibiotics as scheduled. This affected two residents (Resident #44 and Resident #99) out of five residents reviewed for medication administration. Findings include: 1. Resident #44 was admitted to the facility at 5:45 P.M. on 10/27/22 with diagnoses including cellulitis of the lower extremities, bacteremia, elevated white blood cell count, heart failure, chronic kidney disease and obesity. A review of a nurse progress note dated 10/27/22 indicated the physician verified the admission medication orders at 6:45 P.M. A review of Resident #44's clinical nurse practitioner (CNP) progress note dated 10/28/22 indicated Resident #44 was admitted from the hospital for intravenous infusion of antibiotics for the lower leg cellulitis with associated bacteremia infection. The CNP progress note indicated Resident #44 had a peripheral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.