Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Oak Hills Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain the building in good repair, with widespread dents, chipped paint, holes in walls, missing baseboards, unpainted patched areas, a missing transition strip, and damaged bathroom doors in multiple resident rooms and hallways, including areas near the nursing station, therapy gym, and smoking area. Leadership acknowledged awareness of the damage and reported that the maintenance director had quit and that repairs were handled in-house.
Surveyors found that hot water temperatures in multiple rooms on one hallway were consistently below the facility’s desired range of 110–120°F, with documented readings as low as 85°F and no evidence of follow-up or adjustment. A resident reported that her bathroom sink water had been cold for at least a month, and an asset management leader confirmed that recorded temperatures were not acceptable and could have been corrected by adjusting the mixing valve. The facility’s policy limited water to not more than 120°F and required weekly checks and reporting of water that was too hot or too cold, but it did not specify a lower limit for water temperature.
The facility failed to prevent and control resident possession and distribution of marijuana vape pens, leading to safety concerns for two residents. One resident with cognitive impairment and multiple neurologic and psychiatric diagnoses experienced acute confusion, incontinence, and difficulty ambulating, later testing positive for marijuana and being observed with a vape pen obtained from another resident. Another cognitively intact but functionally dependent resident, under a behavior contract prohibiting illegal or unauthorized substances and with a history of issues related to marijuana vape pens and LOAs, was reported to have repeatedly possessed marijuana vape pens and attempted to give one to another resident before staff intervened. Facility leadership and clinical staff were aware of ongoing concerns about this resident bringing in or possessing marijuana vape products despite a policy barring residents from possessing or distributing illegal substances.
A resident with a pressure ulcer, cognitive impairment, and total dependence for ADLs had physician orders and posted signage requiring Enhanced Barrier Precautions, including gloves and a gown, during sacral wound care. During an observed dressing change, two LPNs entered the room, donned gloves but did not wear gowns, and completed the treatment despite the EBP requirements and facility policy stating gowns must be used for wound/pressure ulcer dressing changes. One LPN later acknowledged she should have worn a gown, while the other stated she believed gloves alone were sufficient.
Surveyors found that multiple residents' rooms had issues such as crumbling drywall, mold, water stains, missing tiles, sinks pulling away from walls, deep gouges, and base molding coming off. The Director of Maintenance confirmed these problems, including the presence of mold and water damage, and acknowledged that repairs were needed. These deficiencies showed the facility did not maintain a safe, clean, and comfortable environment as required by its preventative maintenance policy.
The facility did not follow its smoking policy in the designated outdoor area, as observed by an administrator. Numerous cigarette butts were found on the ground and in overfilled, combustible plastic receptacles, with additional butts mixed in piles of leaves. The facility had identified multiple residents who actively smoked, but did not provide noncombustible ashtrays as required by policy.
A facility failed to ensure PRN psychotropic medications were monitored by a physician and had a stop date after 14 days. A resident with Parkinson's, anxiety, and insomnia was prescribed Ativan as needed for anxiety without a stop date, confirmed by the DON.
A facility failed to timely disburse funds after a resident's death, resulting in a deficiency. The resident, with chronic kidney disease and dementia, had a credit due to an overpayment. The refund was delayed as the facility awaited a Medicare decision, and there was no communication with the responsible party. The refund was sent beyond the required 30-day period.
Failure to Maintain Building in Good Repair Throughout Facility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain the building in good repair, which had the potential to affect all 63 residents. During an environmental tour, they observed widespread physical damage in resident rooms and hallways, including general dents and chipped paint on walls throughout the building. In the hallway outside one resident’s room, there was a hole in the wall near the floor behind a carpeted wall. Inside that resident’s room, there were holes on both sides of the bathroom door. An empty resident room showed significant wall damage on the window wall and missing baseboards. Near the nursing station, the adjacent wall and the area surrounding the thermostat had been patched but left unpainted, and the baseboard on the side of the nursing station was missing. In the hallway by the therapy gym and smoking area, the ceiling had been patched but remained unpainted. Additional observations showed missing or damaged structural elements in multiple resident areas. The rubber baseboard was missing between the bathroom and the entrances to two pairs of residents’ rooms, and the wall between the bathroom and the entrance to another resident’s room was unpainted. A missing transition strip was noted in the doorway of another pair of residents’ rooms. There was a large hole in the wall between the bathroom and the entrance to another pair of residents’ rooms, and the bathroom door for those residents had large holes on both sides. In a follow-up tour and interviews, the Director of Asset Management confirmed these findings and reported that the maintenance director had quit. The Vice President of Asset Management also acknowledged awareness of the physical damage and stated that the facility’s maintenance team handled all repairs in-house. This deficiency was investigated under Complaint Number 2719863.
Failure to Maintain Resident Hot Water Temperatures Within Acceptable Range
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident hot water temperatures within an acceptable range to promote comfort in resident rooms on the 100 hallway. During an observation, surveyors measured a resident bathroom sink temperature at 104°F using the facility’s digital thermometer, which the Regional Director of Asset Management confirmed was not within the facility’s desired range of 110–120°F. A resident reported that the water in her bathroom sink had been cold for at least a month, though at the time of interview she noted it was then a little warm. The facility’s census was 63, and 10 residents on the 100 hallway were identified as potentially affected. Review of water temperature logs for multiple rooms on the 100 hall over a period from a specified date through February 2026 showed repeated low readings, including temperatures such as 85°F, 90°F, 91°F, 92°F, 95°F, 97°F, 99°F, 100°F, and 101°F, with no documented evidence of any adjustments to the water temperature or follow-up checks. The President of Asset Management stated that the former maintenance director had quit about one week prior and acknowledged that the water temperatures recorded for the 100 hall were not within an acceptable range and that the low temperatures could have been remedied by adjusting the mixing valve. The facility’s “Safe Water Temperatures” policy required staff to report water that was too hot or too cold and stated that water temperatures would not exceed 120°F and would be checked weekly by maintenance, but it did not define a lower temperature limit.
Failure to Prevent Resident Possession and Distribution of Marijuana Vape Pens
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety related to the use and distribution of marijuana products, resulting in accident hazards and inadequate supervision. One resident with schizophrenia, vascular dementia with behavioral disturbance, aphasia following cerebral infarction, and diabetes mellitus had moderately impaired cognition and required setup or cleanup assistance for ADLs. On one morning, staff found this resident standing in a puddle of urine, and later the same day, the resident was noted to have a change in mental status, difficulty ambulating, and was found on hands and knees urinating on the floor with a saturated bed, requiring assistance from three staff members. The resident was sent to the ED for confusion, where he was normally alert and oriented but had become altered; lab testing showed a positive urine drug screen for marijuana. Upon return to the facility that day, nursing documentation described the same resident sitting on the bed with pants removed, refusing clean clothing, being unsteady on his feet, and smiling or laughing at inappropriate times. A subsequent nursing note documented that this resident had obtained a vape pen from another resident, and the DON and physician were notified, with orders to monitor behavior closely. Interviews later confirmed that facility leadership was aware that the resident had possessed a marijuana vape pen belonging to another resident around the time of the altered mental status and incontinence episode, though it was unclear whether the pen had been taken or given. A second resident, with diagnoses including diabetes mellitus, bipolar disorder, obsessive compulsive disorder, traumatic subdural hemorrhage, and a history of TIA and cerebral infarction, had intact cognition but was dependent on staff for ADLs and had physician orders permitting independent LOAs for several hours per day. This resident had a behavior contract specifying that illegal or unauthorized substances were not permitted, all medications would be administered by staff, and that the resident agreed to follow facility rules, including adherence to smoking policies and allowing room searches. Nursing notes documented multiple LOAs with a nephew, and a late entry note indicated that the RDCS was notified that this resident had attempted to give another resident a vape pen, which nursing staff intervened to remove. Interviews with the ADON and RDCS revealed that this resident had an ongoing issue with possessing marijuana vape pens since around October, had previously had LOA privileges revoked due to drug use, and was believed to be the source of marijuana vape pens within the facility, including the pen obtained by the first resident. The facility’s policy prohibited residents from possessing or distributing illegal substances but did not define illegal drugs.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow Enhanced Barrier Precautions (EBP) during wound care. Resident #16, admitted on 09/24/25, had diagnoses including muscle weakness, a pressure ulcer of the right buttock, infrarenal abdominal aortic aneurysm, and restless legs syndrome. A Minimum Data Set dated 02/18/26 documented memory impairment, total dependence on staff for all ADLs, and continuous bowel and bladder incontinence. Physician orders dated 02/24/26 directed staff to wear gloves and a gown when providing treatment to the resident’s sacral wound, which included cleansing with normal saline, patting dry with gauze, applying calcium alginate, and covering with a super absorbent dressing every day shift and as needed. On 03/03/26 at 2:15 P.M., surveyors observed wound care being performed on Resident #16 by LPN #838 and LPN #833. A sign posted outside the resident’s room indicated the resident was on EBP. Both LPNs gathered treatment supplies, entered the room, and donned gloves but did not put on gowns while completing the wound treatment. In interviews immediately following the observation, LPN #838 acknowledged the resident was on EBP and confirmed she should have worn an isolation gown during the treatment. LPN #833 confirmed she had not worn a gown and was unable to state why a gown was required, stating she believed only gloves were necessary. Review of the facility’s Transmission-Based (Isolation) Precautions policy, dated 09/01/22, showed that EBP, including gown use, are required when completing a dressing change on a wound or pressure ulcer.
Failure to Maintain Facility Environment in Good Repair
Penalty
Summary
Surveyors identified that the facility failed to maintain the physical environment in good repair, affecting six of nine residents reviewed for environmental conditions. Observations included crumbling drywall, unknown black substances (confirmed as mold in some cases), brown stains from water leaks, missing wall tiles, sinks pulling away from walls, deep gouges in walls, and base molding coming off near bathroom doors. In one instance, a large area of adhesive residue was left on a wall after a protective board was removed by a resident, and the adhesive was not cleaned up. These issues were verified by the Director of Maintenance during interviews, who acknowledged the presence of mold, water damage, and the need for repairs. The facility's preventative maintenance policy required the environment to be safe, functional, sanitary, and comfortable for residents, staff, and the public. However, the observed deficiencies, including mold, water damage, and unrepaired structural issues, demonstrated non-compliance with this policy. The findings were substantiated through direct observation, staff interviews, and resident interviews, and were investigated under a specific complaint number.
Failure to Implement Smoking Policy and Maintain Safe Smoking Area
Penalty
Summary
The facility failed to implement its resident smoking policy in the designated outside smoking area. During an observation with the Administrator, approximately 75 to 100 cigarette butts were found scattered on the ground, with additional cigarette butts mixed in piles of leaves. Six cigarette receptacles made of combustible plastic were present, each about 75% or more full, and a seventh receptacle, a plastic bucket, was over 90% full. In total, three to four hundred cigarette butts were observed in the area, both on the ground and in receptacles. The facility had identified twenty residents who actively smoked. Review of the facility's policy indicated that ashtrays made of noncombustible material and safe design were required, but this was not followed as combustible plastic containers were used.
Failure to Monitor PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were monitored by a physician and had a stop date after 14 days of use. This deficiency affected one of the three sampled residents reviewed for unnecessary medications. The resident, who was admitted to the facility with diagnoses including Parkinson's disease, anxiety, and insomnia, was identified as cognitively impaired in a quarterly assessment. The resident's medication list revealed an order for Ativan, an anti-anxiety medication, to be administered every eight hours as needed for anxiety, starting on 10/16/24. However, the Ativan order did not include a stop date, and it remained active as of 11/25/24. This oversight was confirmed during an interview with the Director of Nursing.
Delayed Disbursement of Resident Funds After Death
Penalty
Summary
The facility failed to ensure a timely final accounting and disbursal of funds following the death of a resident. The resident, who was admitted with chronic kidney disease, dementia, and altered mental status, was severely cognitively impaired and required extensive assistance for daily activities. Upon the resident's death, a credit of $7,115.04 was noted in the financial records, which was due to an overpayment for the upcoming month's care. However, the refund was not sent to the responsible party within the required 30-day period. The delay in disbursing the funds was attributed to the facility awaiting a potential Medicare coverage decision for part of the resident's stay. A formal denial from Medicare was received, but there was no communication with the resident's responsible party regarding the refund status. The Regional Business Office Manager confirmed that the refund was sent out beyond the 30-day requirement, leading to the deficiency noted in the complaint investigation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 392 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lorain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Pointe Health Care | 0.4 mi | ★★★★★ | 0 | 0 |
| Anchor Lodge Nursing Home Inc | 1.6 mi | ★★★★★ | 10 | 0 |
| Amherst Manor Nursing Home | 2.6 mi | ★★★★★ | 0 | 0 |
| Autumn Aegis Nursing Home | 3.1 mi | ★★★★★ | 0 | 0 |
| Kingston Health Center Of Vermilion | 4.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oak Hills Nursing Center.
100% money-back within 48 hours.
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.