Above 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 Community Hospital Onaga Ltcu during CMS and state inspections, most recent first.
A facility failed to complete the Comprehensive MDS for a resident by not analyzing triggered CAAs, risking an inaccurate care plan. The resident had multiple diagnoses, including dementia and hemiplegia, and required full staff assistance. An administrative nurse was unaware of the requirement to complete CAAs, believing them optional unless needed for care planning. The facility's policy required comprehensive assessments, but the lack of CAA analysis left the resident's care needs potentially unidentified.
A resident with a history of falls and severely impaired cognition experienced multiple falls without consistent implementation of preventive interventions. Despite being identified as a fall risk, the facility failed to document new interventions after each fall, as required by their protocol. This deficiency placed the resident at risk for further falls and injuries.
A facility failed to ensure proper collaboration with hospice services for a resident with a terminal prognosis related to dementia. The care plan lacked essential information about hospice services, leading to staff confusion and reliance on facility supplies. This deficiency placed the resident at risk for impaired end-of-life care.
Incomplete Comprehensive MDS and CAA Analysis for a Resident
Penalty
Summary
The facility failed to fully complete the Comprehensive Minimum Data Set (MDS) for a resident, identified as R3, by not completing an analysis for triggered Care Area Assessments (CAA). This deficiency was identified during a survey that included a sample of 12 residents out of a census of 23. R3's electronic medical record documented several diagnoses, including mood disorder, dementia, weakness, anxiety, hemiplegia, hypertension, and anemia. The resident had a severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of zero and was dependent on staff for all functional abilities, requiring the use of a Broda chair for mobility and enteral nutrition. The resident's CAA triggered for multiple areas, including cognitive loss/dementia, communication, urinary incontinence, and others, but lacked completion with analysis of findings. The deficiency was further highlighted when an administrative nurse stated she was unaware that the CAA needed to be filled out, as she was under the impression they were optional unless needed for the care plan. She had been performing MDS assessments for three years and had just received training, during which she learned that each triggered CAA required resident analysis documentation. The facility's Comprehensive Assessment policy, reviewed in 2019, required comprehensive, accurate, and standardized assessments of each resident's functional capacity, including direct observation and communication with the resident and staff. The failure to complete the triggered CAA placed the resident at risk for an inaccurate plan of care and unidentified care needs.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement interventions to prevent falls for Resident 19, who had multiple falls. Resident 19's medical record documented restlessness, agitation, frontotemporal neurocognitive disorder, and pain, with a severely impaired cognition score. The resident had a history of falls, some resulting in injuries such as skin tears and bruising. Despite being identified as a fall risk, the facility did not consistently apply interventions to prevent further falls. Resident 19's care plan included measures such as ensuring the call light was within reach, providing a low-stimulation environment, and keeping the tray table away from the resident's path. However, the facility's records showed multiple instances where falls occurred without evidence of new interventions being implemented. For example, falls on 09/02/24, 09/05/24, 09/14/24, 09/26/24, 10/15/24, and 10/18/24 lacked documentation of any new interventions being put in place to address the falls. Interviews with facility staff revealed that interventions were supposed to be added after a fall, either immediately or after a team huddle. However, the clinical records for Resident 19 did not reflect this practice, indicating a failure to follow through with the facility's fall prevention protocol. This lack of consistent intervention placed Resident 19 at risk for further falls and related injuries.
Inadequate Collaboration with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration between the nursing home and hospice services for a resident identified as R19, who was receiving hospice care due to a terminal prognosis related to dementia. The resident's care plan lacked essential information regarding the hospice provider's contact details, the frequency of visits, and the specific supplies, equipment, and medications provided by hospice. This lack of information led to confusion among staff members, as evidenced by interviews with a Licensed Nurse and a Certified Nursing Aide, who were unsure about the hospice services and supplies available to the resident. The deficiency was further highlighted by the facility's Hospice Services policy, which mandates that each resident should receive necessary care and services in accordance with a comprehensive assessment and plan of care. Despite this policy, the administrative nurse admitted uncertainty about the medications that should be included in the care plan, and there was a reliance on facility supplies if hospice supplies ran out. This inadequate collaboration and communication placed the resident at risk for impaired end-of-life care, as the facility did not effectively coordinate with hospice services to ensure the resident's needs were met.
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 173 citations issued within 25 miles in the last 12 months — including the 3 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 St Marys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rossville Healthcare And Rehabilitation Center | 7.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Valley Vista | 13.9 mi | ★★★★★ | 0 | 0 |
| Westy Community Care Home | 18.1 mi | ★★★★★ | 0 | 0 |
| The Healthcare Resort Of Topeka | 18.1 mi | ★★★★★ | 8 | 0 |
| Rolling Hills Health Center | 18.8 mi | ★★★★★ | 9 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Community Hospital Onaga Ltcu.
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.