Addison Healthcare Center

In the surveyor’s words

From the most serious findings on record at Addison Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF602Feb 25, 2025

  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. […]

• No harm, potential for more than minimal, patternF565Apr 29, 2021

  Based on observation, interview, record, resident council and review of shower/bathing records, the facility failed to act upon grievances of the residents. This affected at five (#7, #8, #22, #33 and #42) of six residents (#43) reviewed with the potential to affect all 47 residents. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly comprehensive assessment (MDS 3.0) dated 01/27/21 indicated she was independent in daily decision making ability, displayed no behavioral symptoms, required the extensive assistance of two plus staff for personal hygiene and totally dependent on two plus staff for bathing. […]

• No harm, potential for more than minimal, patternF677Apr 29, 2021

  Based on observation, interview, record, resident council and review of shower/bathing records, the facility failed to provide showers/baths to residents who were unable to shower independently. This affected at least five (#7, #8, #22, #33 and #42) of six residents (#43) reviewed with the potential to affect all 47 residents. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly comprehensive assessment (MDS 3.0) dated 01/27/21 indicated she was independent in daily decision making ability, displayed no behavioral symptoms, required the extensive assistance of two plus staff for personal hygiene and totally dependent on two plus staff for bathing. […]

• No harm, potential for more than minimal, isolatedF584Mar 19, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF656Mar 19, 2026

  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. […]