Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oaks Of Brecksville during CMS and state inspections, most recent first.
A resident admitted with a dehisced surgical wound did not receive prescribed wound care for several days because hospital discharge orders were not transcribed or implemented by staff. The wound was not properly assessed or treated, leading to infection with purulent drainage and significant slough. The issue was discovered when a nurse noticed a foul odor and found the dressing saturated, prompting initiation of appropriate care and antibiotics. The resident's condition deteriorated, requiring hospital transfer.
A DON diverted large quantities of controlled substances, including morphine and oxycodone, over a two-year period by removing discontinued or unneeded medications from medication carts without proper destruction or documentation. The DON falsified records and self-administered the drugs, with the misappropriation only discovered after the DON was observed impaired at work and tested positive for multiple narcotics. Facility policies requiring witnessed destruction and documentation were not followed, resulting in hundreds of missing doses affecting several residents.
The facility failed to properly label and store insulin pens for multiple residents, with missing open dates and identifiers. Additionally, a resident's medication was left unattended, contrary to facility policy. An RN and an LPN confirmed these deficiencies during observations.
The facility failed to ensure proper infection control measures, including the inappropriate sanitization of glucometers and failure to maintain isolation precautions. A nurse used an alcohol swab instead of the required disinfectant for a glucometer, and both a nurse and a nursing student entered rooms of residents under contact precautions without proper PPE, risking the spread of infections.
The facility failed to ensure consistent documentation of advance directives across electronic and paper records for two residents. One resident's records showed discrepancies between the EMR, paper record, and care plan regarding their advance directive status. Another resident's EMR and care plan were consistent, but the paper record lacked documentation of the advance directive. The DON confirmed these inconsistencies and the facility's policies did not adequately address the documentation process.
The facility failed to maintain clean and sanitary resident care equipment, affecting three residents. A resident's power wheelchair was found dirty with dried food debris, and two residents' fall mats were unclean and damaged. The facility's policy lacked specific cleaning instructions for wheelchairs.
Failure to Transcribe and Implement Wound Care Orders Resulting in Infection
Penalty
Summary
A deficiency occurred when a resident was admitted with a dehisced surgical wound to the lower back and specific wound care orders from the hospital, including cleansing with vashe, application of aquacel AG advanced, and covering with a mepilex dressing. These orders were not transcribed or implemented by facility staff for six days following admission. During this period, nursing staff documented that the surgical site was clean and dry, but did not follow the prescribed wound care regimen. The resident, who had diagnoses including a stable burst fracture of the fifth lumbar vertebra and uterine cancer, was dependent on staff for personal care and was incontinent of bowel and bladder. The wound was not assessed or treated according to the hospital's discharge instructions, and the facility's wound nurse was not made aware of the wound until several days after admission. The omission was discovered when a nurse detected a foul odor and found the dressing saturated with purulent drainage, indicating infection. At that point, the nurse located the original hospital orders and implemented the appropriate wound care, and the resident was started on antibiotics after the infection was identified. The delay in transcribing and implementing the wound care orders resulted in the resident developing an infected surgical wound with purulent drainage and significant slough covering most of the wound bed. The resident subsequently became lethargic and was transferred to the hospital for further evaluation. The failure to follow the physician's orders for wound care directly led to the infection and deterioration of the resident's condition.
Misappropriation of Controlled Substances by DON
Penalty
Summary
The facility failed to protect residents from misappropriation of their controlled medications, specifically narcotic pain medications such as morphine, oxycodone, fentanyl, hydrocodone, and tramadol. Over a period spanning from 2023 to 2025, multiple instances of missing controlled substances were identified, affecting five residents. The former Director of Nursing (DON) was found to be the only staff member with access to the office where the medications were stored, and was observed to be impaired at work, including symptoms such as vomiting, slurred speech, and unsteadiness. A urine drug screen conducted on the DON returned positive results for morphine, oxycodone, and benzodiazepines. Investigations by the facility, local police, Board of Nursing, and Board of Pharmacy revealed that the former DON had diverted controlled substances by removing discontinued, deceased, or discharged residents' medication cards from medication carts without proper documentation or destruction. The DON admitted to falsifying destruction records and self-administering the diverted medications. The facility's incident logs, police reports, and pharmacy audits documented significant discrepancies in narcotic counts, with hundreds of doses unaccounted for over the two-year period. The DON also admitted to notifying the pharmacy that medications were destroyed when they were not, and the destruction logs lacked required witness signatures. Facility policy required that controlled substances be destroyed in the presence of a Registered Nurse and another licensed professional, with proper documentation of the destruction process. However, the investigation found that these procedures were not followed, and the DON was able to divert medications without detection until the incident was discovered in February 2025. There were no prior suspicions or reports of the DON being under the influence or diverting medications before this time, and the facility had not previously identified or reported any discrepancies related to narcotics.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of insulin multi-dose syringe pens, affecting five residents. During a medication administration procedure, it was observed that insulin pens for several residents lacked open dates and proper resident identifiers. Specifically, Resident #13's Soliqua pen and Resident #50's insulin Lispro and Glargine pens had no open dates. Additionally, Resident #49's insulin Glargine pen was also missing an open date, and two pens labeled with initials B.H. had no name, with one missing an open date. RN #533 confirmed these findings, noting that the pens labeled B.H. belonged to Resident #46. The facility's pharmacy storage recommendations indicated that these medications should only be stored for 28 days after opening or when kept at room temperature. In another instance, the facility failed to ensure medications were properly administered and not left unattended. Resident #26, who had a diagnosis of diabetes and hypertension, was observed with a medication cup containing Levetiracetam left on a stand by her wheelchair. The resident stated that the nurse had forgotten to administer it. LPN #529 confirmed that he had left the medication unattended and acknowledged that the resident was not able to self-administer her medication. The facility's policy on medication administration clearly stated that medications should not be left unattended, highlighting a breach in protocol.
Infection Control Deficiencies in Glucometer Sanitization and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by the inappropriate sanitization of glucometer devices and failure to maintain isolation precautions. During a medication administration procedure, a registered nurse used an alcohol swab to disinfect a glucometer after testing a resident's blood glucose, contrary to the manufacturer's instructions which required specific disinfectants. This oversight was confirmed by the nurse, who mentioned that the appropriate disinfectant wipes were on order. The improper disinfection of glucometers poses a risk of transmitting bloodborne pathogens such as Hepatitis C. In another instance, a licensed practical nurse entered a resident's room without wearing the required personal protective equipment (PPE) despite the resident being under contact precautions due to an infection with extended-spectrum beta-lactamase (ESBL) in the urine. The nurse acknowledged the signage indicating the need for PPE but failed to comply, thereby increasing the risk of spreading infectious agents through direct or indirect contact. Additionally, a nursing student entered a resident's room, who was under contact isolation precautions for Enterococcus faecalis, without donning gloves or a gown. The student assisted the resident with their breakfast tray, potentially contaminating the environment. Despite being aware of the isolation precautions and the presence of an isolation cart with supplies, the student did not adhere to the required protocols, which was later confirmed by a licensed practical nurse who observed the breach in protocol.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directive orders were consistent across electronic and paper medical records for two residents. Resident #13's records showed discrepancies between the electronic medical record (EMR), paper medical record, and care plan regarding the advance directive status. The EMR indicated a full code status, while the care plan noted a Do Not Resuscitate Comfort Care Arrest (DNRCCA) directive. The paper medical record also indicated a full code status, and there was no physician's order for any advance directive in the EMR. The Director of Nursing (DON) confirmed these inconsistencies during an interview. For Resident #225, the EMR and care plan indicated a DNRCCA/Do Not Intubate (DNI) status, consistent with a physician's order. However, the paper medical record lacked any documentation of an advance directive, and the hospital discharge summary did not include a formal advance directive. The DON verified the absence of a written DNR form in the resident's chart and explained the facility's process for documenting advance directives, which was not followed in this case. The facility's policies did not adequately address the documentation process for advance directives.
Deficiency in Maintaining Clean Resident Care Equipment
Penalty
Summary
The facility failed to maintain resident care equipment in a clean and sanitary condition, affecting three residents. Resident #4, who has diagnoses including heart failure and dysphagia, was observed with a dirty power wheelchair during medication administration. The wheelchair had dried food debris on the armrest and frame, and the right armrest and controller were leaning over the side. A State tested Nurse Aide confirmed the condition of the wheelchair and mentioned that Resident #4 had behaviors such as throwing food, necessitating cleaning after every meal. However, the facility's policy on cleaning and disinfecting resident care equipment lacked specific instructions for cleaning wheelchairs. Additionally, the mats used for fall interventions for Residents #75 and #76 were found to be unclean, with various colored substances on them. Resident #75's mat also had significant tears. Both residents had care plans indicating the use of mats due to fall risks, with Resident #75 having a right leg amputation and Resident #76 having impaired cognition and mobility. The facility administrator verified the poor condition of the mats during an interview. This deficiency was investigated under Complaint Number OH00156493.
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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 Brecksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heights Rehabilitation And Healthcare Center, The | 1.5 mi | ★★★★★ | 3 | 0 |
| Brentwood Health Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Avenue At Broadview Heights | 3.3 mi | ★★★★★ | 14 | 0 |
| Regina Health Center | 4.6 mi | ★★★★★ | 2 | 0 |
| Momentous Health At Richfield | 4.8 mi | — | 21 | 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.