Safety Report: Oak Hill Center For Rehabilitation and Nursing
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
6Actual harm citations (severity G–I)
14Requirements cited on more than one inspection
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
G
Government finding: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies · Tag F805
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
Citations by topic
5Abuse, neglect & exploitation
2Infection control
5Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (10) than in the cycle before (21).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 5 | April 7, 2026; December 4, 2025; September 11, 2025; October 30, 2024; May 1, 2024 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 3 | June 4, 2025; April 8, 2024; November 29, 2023 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. (F698) | 2 | December 4, 2025; November 21, 2024 |
| Provide or obtain dental services for each resident. (F791) | 2 | December 4, 2025; November 21, 2024 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690) | 2 | December 4, 2025; January 25, 2024 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | December 4, 2025; April 8, 2024 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 2 | December 4, 2025; January 25, 2024 |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (F805) | 2 | June 4, 2025; April 24, 2025 |
| Provide and implement an infection prevention and control program. (F880) | 2 | November 21, 2024; January 25, 2024 |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (F761) | 2 | November 21, 2024; January 25, 2024 |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (F688) | 2 | November 21, 2024; January 25, 2024 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 2 | November 21, 2024; January 25, 2024 |
| Ensure each resident receives an accurate assessment. (F641) | 2 | November 21, 2024; January 25, 2024 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | November 21, 2024; January 25, 2024 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| October 30, 2024 | Fine | $44,777 |
| April 8, 2024 | Fine | $8,988 |
| April 8, 2024 | Fine | $8,167 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
April 7, 2026 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected May 4, 2026
December 4, 2025 — 9 citations
E
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F730 · corrected January 12, 2026
E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F698 · corrected January 12, 2026
E
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F697 · corrected January 12, 2026
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected January 12, 2026
E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F605 · corrected January 12, 2026
D
Provide or obtain dental services for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F791 · corrected January 12, 2026
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected January 12, 2026
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected January 12, 2026
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected January 12, 2026
September 11, 2025 — 1 citation (includes serious) · complaint investigation
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected September 18, 2025
August 4, 2025 — 1 citation · complaint investigation
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected August 19, 2025
June 4, 2025 — 2 citations (includes serious) · complaint investigation
G
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Actual harm to a resident (not immediate jeopardy) · Isolated · Nutrition and Dietary Deficiencies · F805 · complaint · corrected June 17, 2025
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected June 13, 2025
April 24, 2025 — 1 citation · complaint investigation
D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · complaint · corrected May 15, 2025
November 21, 2024 — 15 citations
E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F909 · corrected December 16, 2024
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected December 16, 2024
E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected December 16, 2024
E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F700 · corrected December 16, 2024
E
Provide care or services that was trauma informed and/or culturally competent.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F699 · corrected December 16, 2024
E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F693 · corrected December 16, 2024
E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F688 · corrected December 16, 2024
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · corrected December 16, 2024
E
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · corrected December 16, 2024
E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F582 · corrected December 16, 2024
E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F553 · corrected December 16, 2024
D
Provide or obtain dental services for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F791 · corrected December 16, 2024
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected December 16, 2024
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected December 16, 2024
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected December 16, 2024
October 30, 2024 — 1 citation (includes serious) · complaint investigation
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected November 25, 2024
May 1, 2024 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected June 9, 2024
April 8, 2024 — 2 citations (includes serious) · complaint investigation
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected April 30, 2024
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected April 30, 2024
January 25, 2024 — 23 citations
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected February 20, 2024
E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F868 · corrected February 20, 2024
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected February 27, 2024
E
Provide routine and 24-hour emergency dental care for each resident.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F790 · corrected February 20, 2024
E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F758 · corrected February 20, 2024
E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F756 · corrected February 20, 2024
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected February 20, 2024
E
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F692 · corrected February 27, 2024
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected February 20, 2024
E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected February 20, 2024
E
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · corrected February 20, 2024
E
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F606 · complaint · corrected February 20, 2024
E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F585 · complaint · corrected February 20, 2024
E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected February 20, 2024
D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F810 · corrected February 27, 2024
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected February 20, 2024
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected February 20, 2024
D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected February 20, 2024
D
Assist a resident in gaining access to vision and hearing services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F685 · corrected February 20, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected February 20, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected February 20, 2024
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · complaint · corrected February 20, 2024
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected February 20, 2024
November 29, 2023 — 2 citations · complaint investigation
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected January 18, 2024
D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F559 · complaint · corrected January 18, 2024
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare