Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Addison Healthcare Center during CMS and state inspections, most recent first.
Inadequate water temperature in a resident bathroom sink. A cognitively intact resident who needed staff help with ADLs reported the sink water was never hot, and observation showed the water reached only 80°F while he brushed his teeth and confirmed it remained cold. The Maintenance Director stated water temperatures in some rooms on the 100-hall were often not within the required range and were sometimes as low as 50°F, especially when the dishwashing machine and laundry were running.
Incomplete care plans failed to address key resident needs for depression, wound care, and medical transportation. One resident with depression had an antidepressant order and monitoring instructions, but the care plan did not include depression. Another resident with multiple pressure ulcers and deep tissue injuries had wound care orders, Prevalon boots, and heel off-loading instructions, but the care plan only listed general skin integrity interventions. A third resident needed medical transportation for an orthopedic follow-up, but that need was not included in the care plan, and the resident reported the missed transport delayed discharge plans.
A resident with intact cognition and multiple medical diagnoses missed an orthopedic follow-up because the facility did not arrange needed transportation. The resident reported frustration that the appointment was not scheduled for transport, delaying discharge plans, and the ADON stated she was never notified by the floor nurse to set up the ride. The facility policy stated it would assist residents with transportation arrangements for physician visits when needed.
Failure to use ordered heel offloading for a resident with multiple pressure ulcers. A resident with sepsis, respiratory failure, HF, kidney failure, and malnutrition had a Stage IV PU, multiple unstageable wounds, and DTI. Although the MD ordered Prevalon boots while in bed and heel floating, the care plan did not include the boots, and during observation the resident was in bed with uncovered feet, no boots in place, and heels not elevated. The resident said he did not think he needed the boots anymore, and the BOM confirmed no boots were in the room.
Failure to assess and document adaptive eating equipment for a resident with therapy-recommended built-up utensils. A resident with DM and diabetic polyneuropathy had a therapy order for built-up utensils at all meals, but no OT eval was completed, no physician order was in place, and the care plan and MDS did not reflect the adaptive utensils. The resident reported not always receiving the utensils and having to ask for them, while staff stated he used them and an observation showed them on his tray.
Infection Prevention Failure During Wound Care: A resident with a stage IV coccyx pressure ulcer, severe cognitive impairment, and diabetes received wound care with exposed bone while the RN placed supplies on uncleaned surfaces and did not wear a mask despite a splash risk. The RN confirmed the resident was on EBP and that the wound treatment posed a splash risk, while facility policy required PPE and a clean work surface for dressing changes.
A former RN at an LTC facility misappropriated controlled substances, including Oxycodone, Percocet, Morphine Sulfate, and Xanax, from several residents. The RN was found unresponsive in the facility bathroom with the missing medications and was administered Narcan by police. Residents were assessed and reported no delay in receiving their medications.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a PEG tube during medication administration. An intern RN did not wear a gown, despite signage indicating EBP was required. The resident had spastic quadriplegic cerebral palsy and other conditions necessitating EBP. The Director of Nursing confirmed the need for EBP, as outlined in facility policy and CMS guidelines.
Inadequate Water Temperature in Resident Bathroom Sink
Penalty
Summary
The facility failed to ensure appropriate water temperatures in a resident bathroom sink. Resident #25, admitted on 07/13/23 with diagnoses including kidney disease, depression, glaucoma, hypertension, and irritable bowel syndrome, was assessed as cognitively intact on the quarterly MDS and required varying levels of assistance with daily care, including dependence on staff for toileting, showering, dressing, and personal hygiene. During interview, the resident stated the water in his bathroom sink was never hot. On observation, the sink in Resident #25's room reached only 80 degrees Fahrenheit, and the resident was seen brushing his teeth while confirming the water remained cold. The Maintenance Director stated that water temperatures in some rooms on the 100-hall, including Resident #25's room, were often not within the required range and that the 80-degree reading was warmer than the 50 degrees he often observed. He also stated that when the dishwashing machine and laundry were running between 8:00 A.M. and approximately 2:00 P.M., the water was often not warm. The facility policy stated residents had the right to a safe, sanitary, and respectful environment that supports comfort, dignity, and personal well-being, including access to essential daily needs such as bathing, grooming, and hygiene.
Incomplete Care Plans for Depression, Wound Care, and Transportation Needs
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for residents with identified needs. For Resident #2, the record showed an admission date of 02/20/26 and diagnoses including cerebral infarction, diabetes, dementia, heart disease, depression, and kidney disease. The comprehensive MDS assessment indicated the resident was cognitively intact, required supervision for eating, substantial to maximum assistance for oral care, personal care, and showering, and was dependent on staff for toileting. Physician orders included Trazadone 50 mg at bedtime beginning 03/02/26 and an order to monitor for antidepressant side effects beginning 02/23/26, but the care plan dated 03/02/6 did not address depression. For Resident #50, the record showed an admission date of 02/06/26 and diagnoses including sepsis, respiratory failure, heart failure, kidney failure, and malnutrition. The comprehensive MDS assessment indicated the resident was cognitively intact and 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. The resident had one Stage IV pressure ulcer, two unstageable pressure ulcers, and three unstageable deep tissue injuries. Physician orders included wound care to the right plantar foot, use of Prevalon boots while in bed, and floating heels and bony prominences while in bed, but the care plan dated 02/11/26 only identified impaired skin integrity and included general interventions such as skin risk assessments, weekly skin checks, turning and repositioning, and an offloading mattress and cushioning as applicable. There was no evidence of Prevalon boots or heel off-loading in the care plan. For Resident #11, the record showed an admission date of 01/27/26 with diagnoses including a nondisplaced fracture of the lateral malleolus of the left fibula, an unspecified injury of the right quadriceps muscle, autoimmune thyroiditis, COPD, and hypertension. The comprehensive care plan dated 01/27/26 did not address the resident’s need for medical transportation. The MDS assessment showed a BIMS score of 15, indicating intact cognition, and the resident required supervision with toileting, moderate assistance with bathing, supervision with upper extremity dressing, moderate assistance with lower extremity dressing, and supervision with personal hygiene. The resident stated that staff failed to schedule and arrange transportation to an orthopedic follow-up appointment, which delayed discharge plans, and the MDS nurse confirmed the transportation need was not included in the comprehensive care plan.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to provide transportation to a medical appointment for a resident with intact cognition and multiple diagnoses, including a nondisplaced fracture of the left fibula, injury of the right quadriceps muscle, autoimmune thyroiditis, COPD, and hypertension. The resident’s MDS showed a BIMS score of 15 and she required varying levels of assistance with toileting, bathing, dressing, and personal hygiene. A physician order documented a follow-up orthopedic post-op appointment, but the resident reported that the facility did not schedule or arrange transportation for the appointment, which delayed her planned discharge home. The resident stated that the missed orthopedic appointment was later rescheduled and that she still needed medical transportation to attend it. The ADON stated she was responsible for arranging transportation for residents’ medical appointments and that floor nurses were expected to place paperwork in her mailbox when transportation was needed. She reported that she was never notified about the resident’s appointment and therefore transportation was never arranged. The facility policy stated that the facility would assist residents in making transportation arrangements to and from needed services such as physician visits when assistance was required.
Failure to Use Ordered Heel Offloading for Resident With Multiple Pressure Ulcers
Penalty
Summary
The facility failed to ensure pressure reducing interventions were in place as ordered for Resident #50, who was admitted with diagnoses including sepsis, respiratory failure, heart failure, kidney failure, and malnutrition. The resident’s MDS showed he was cognitively intact and dependent for toileting, with substantial to maximum assistance needed for showering and partial to moderate assistance for oral and personal hygiene. He had multiple pressure-related wounds, including one Stage IV pressure ulcer, two unstageable pressure ulcers, and three unstageable deep tissue injuries. The care plan addressed impaired skin integrity and included turning and repositioning, weekly skin checks, and an appropriate offloading mattress and cushioning, but it did not include Prevalon boots or heel offloading for the resident’s heels. Physician orders directed that Resident #50 wear Prevalon boots while in bed and have heels and bony prominences floated while in bed. Wound assessments showed an unstageable right plantar foot wound measuring 6 cm by 15 cm with eschar, slough, granulation, and epithelial tissue, and an unstageable left lateral heel wound with 100% slough. During observation, the resident was lying in bed with uncovered feet, no Prevalon boots were in place, and his heels were not elevated. The resident stated he had come to the facility with boots for his heel pressure ulcers but did not believe he needed to wear them anymore and was unsure whether his heels were supposed to be elevated. The BOM confirmed the resident was not wearing anything on his feet and that there were no boots in the room.
Failure to Assess and Document Adaptive Utensils for a Resident
Penalty
Summary
The facility failed to ensure that Resident #7’s therapy recommendation for black built-up utensils at all meals was properly assessed, that a corresponding physician order was obtained, and that the intervention was included in the care plan. Resident #7 was admitted with diagnoses including type II diabetes mellitus with diabetic polyneuropathy and atherosclerotic heart disease of native coronary artery without angina pectoris. The therapist’s order dated 04/21/25 specified black built-up utensils for all meals, but the resident’s MDS did not identify any adaptive equipment or assistive devices for eating, and the care plan dated 02/16/26 did not indicate adaptive utensils for meals. The physician orders also contained no order for adaptive utensils. During interview, Resident #7 stated he does not always get his adaptive utensils for meals and must ask for them. A CNA stated the resident used adaptive utensils for all meals, and observation later showed the resident had adaptive utensils on his lunch tray. The OT stated there was a physician order related to adaptive eating equipment, but no OT evaluation had been completed to assess the resident’s need for, or appropriate use of, adaptive utensils. The facility policy required an OT or ST assessment to determine the need for assistive devices, obtain appropriate equipment, educate staff, and ensure proper use was reflected in the care plan.
Infection Prevention Failure During Wound Care
Penalty
Summary
The facility failed to provide wound care to a resident with a stage IV coccyx pressure ulcer in a manner to prevent infection. The resident had an admission date of 09/03/25 and a readmission date of 01/23/26, with diagnoses including acute respiratory failure with hypoxia, a stage IV sacral pressure ulcer with exposed bone, and type 2 diabetes mellitus. The five-day MDS showed severe cognitive impairment and extensive assistance needed for all activities of daily living. The physician’s order directed the coccyx wound to be cleaned with normal saline, lightly packed with quarter strength Dakin’s moist gauze, and covered with a superabsorbent dressing every shift and as needed, and another order required enhanced barrier precautions every shift. During observation of wound care, the RN brought the treatment cart into the resident’s room and opened wound care supplies, placing them wrapper-side down on the top of the cart and the bedside table without cleaning or covering either surface. The RN removed the dressing, removed gloves, used hand sanitizer, and irrigated the deep coccyx wound with normal saline while the resident’s coccyx bone was exposed. The RN then applied Vaseline gauze over the exposed bone, packed the wound with Dakin’s-soaked gauze, applied barrier cream to the wound edges, and covered it with a dry dressing. The RN confirmed the resident was to be on EBP, confirmed the wound posed a splash risk, and stated she was only wearing glasses and not a mask during the wound care. Facility policy required a mask and eye protection or a face shield during procedures likely to generate splashes or sprays, and required a clean, hard surface work area using disinfectant wipes for dressing changes.
Misappropriation of Controlled Substances by Former RN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their controlled substance narcotic pain medication. This incident involved four residents whose medications were taken by a former RN. The medications included Oxycodone, Percocet, Morphine Sulfate, and Xanax, which were found missing from the medication cart. The police were notified, and the former RN was found unresponsive in the facility bathroom with the missing medication cards. The investigation revealed that the former RN had ingested a significant amount of the stolen medications. The police report confirmed that the RN had left the facility without notifying anyone and had taken the medications. The RN was found in possession of the medications and was administered Narcan by the police officer before being sent to the hospital. The residents affected by this incident were assessed for any adverse effects, and none were noted. The facility's records showed that the residents received their medications as ordered, and there was no delay in administering replacement medications. Interviews with the residents confirmed that they did not experience any delay or issues with their medication administration during the incident.
Failure to Implement Enhanced Barrier Precautions for Resident with PEG Tube
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions (EBP) for a resident during the administration of medication through a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had spastic quadriplegic cerebral palsy, convulsions, dysphagia, and adult failure to thrive, required EBP due to the presence of a PEG tube. The care plan and physician orders indicated the need for EBP, including the use of gloves and gowns during high-contact care activities. However, an intern registered nurse did not wear a gown while administering medication through the PEG tube, despite signage indicating the requirement for EBP. The intern nurse's uniform came into contact with the resident's bedding during the procedure, and she acknowledged not wearing a gown, believing the signage was outdated. The Director of Nursing confirmed that the resident was supposed to be on EBP due to the PEG tube and that the nurse should have worn a gown. The facility's policy and a memorandum from the Centers for Medicare & Medicaid Services outlined the necessity of EBP for residents with indwelling medical devices, even if not infected or colonized with a multi-drug-resistant organism.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Masury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| O'brien Memorial Health Care C | 0.8 mi | ★★★★★ | 6 | 0 |
| Clepper Manor | 2.6 mi | ★★★★★ | 0 | 0 |
| Hermitage Nursing And Rehabilitation | 3.9 mi | ★★★★★ | 5 | 0 |
| Saint John Xxiii Home | 5.2 mi | ★★★★★ | 1 | 0 |
| Meadowbrook Manor | 5.4 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.