Addison Heights Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Addison Heights Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 29, 2023

  Based on medical record review, family interview, staff interview, review of x-ray reports, and review of hospital documents, the facility failed to provide follow up assessments and failed to ensure potential abnormal x-ray results were reported to the facility and physician. This resulted in actual harm based on a reasonable person ' s response of experiencing pain due to the presence of a fracture that was not immobilized, when Resident #50, who had severe cognitive impairment and impairment in her ability to communicate, was identified with a swollen left wrist and pain in the hand. An x-ray was ordered to the hand with no x-ray ordered to the wrist. The hand x-ray captured an image of the wrist, which appeared abnormal. […]

• No harm, potential for more than minimal, widespreadF925May 20, 2026

  Based on medical record review, resident interview, staff interview, pest control vendor interview, review of pest control invoices, review of a staff statement and review of facility policy, the facility failed to maintain an effective pest control program. This affected one (#48) of three residents reviewed for pest control with the potential to affect all residents of the facility. The facility census was 72.Findings include:Review of the medical record for Resident #48 revealed an admission date of 12/18/15. […]

• No harm, potential for more than minimal, widespreadF727Sep 15, 2025

  Based on staff interview, and review of facility staffing documentation, the facility failed to ensure a Registered Nurse was scheduled eight consecutive hours when the facility exceeded a census of 60 residents. This affected all 60 residents residing in the facility. Review of facility staffing documentation and related schedules between 09/01/25 and 09/07/25. Facility census was 61 current residents on 09/04/25, 09/05/25, 09/06/25. The facility Director of Nursing was listed as the only Registered Nurse in the facility. On 09/11/25 at 1:07 P.M. interview with Scheduling Coordinator (SC) #466 during a review of facility schedules between 09/01/25 and 09/07/25 verified no additional Registered Nurse was scheduled in the facility on 09/04/25, 09/05/25, 09/06/25. […]

• No harm, potential for more than minimal, widespreadF761Sep 15, 2025

  Based on observation, staff interview, review of manufactures guidelines, review of pharmacy policy, and review of facility policy, the facility failed to store medications that require refrigeration. This affected Resident #13. The facility failed to ensure the freezer, located inside of the medication-storage refrigerator, was properly maintained. This affected eight residents (#10, #13, #33, #34, #37, #42, #60, and #68) that were identified by the facility as utilizing medications that required refrigeration. The facility also failed to ensure the medication-storage refrigerator maintained the correct temperature parameters to safely store medications that require refrigeration. […]

• No harm, potential for more than minimal, widespreadF802Sep 15, 2025

  Based on observation, staff interviews, resident interviews, and schedule reviews the facility failed to ensure adequate kitchen staff were available to provide timely meal service. This affected all residents. The facility census was 60.Observation of the kitchen staff on 09/08/25 at 8:00 A.M. revealed only Dietary Manager #504 was working in the kitchen and was preparing the breakfast meal.Review of the dietary staffing schedule dated 09/08/25 revealed one cook was scheduled from 6:00 A.M. to 2:00 P.M., and a dietary aide from 7:00 A.M. to 3:00 P.M. and a second aide from 10:00 A.M. to 8:00 P.M. There were two open shifts from 4:00 P.M. to 7:00 P.M. and 7:00 A.M. to 10:00 A.M.Interview with Dietary Manager #504 on 09/08/25 at 8:00 A.M. […]