Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Onaga Operator, Llc during CMS and state inspections, most recent first.
Staff failed to store resident respiratory equipment in a sanitary manner, with CPAP masks, nebulizer masks, and nasal cannulas repeatedly observed lying on beds, bedside tables, or wrapped around oxygen equipment instead of being secured in sanitary containers. Clean linens and clothing were also observed being transported uncovered, and a CNA provided incontinent care and dressing assistance to a resident without performing hand hygiene; the CNA later confirmed she did not wash her hands or have the resident wash hers.
Lack of Certified Dietary Manager: The facility failed to employ a full-time CDM for 28 residents receiving meals from the kitchen. An unlicensed dietary staff member was observed overseeing noon meal prep, and she confirmed she was not yet certified despite completing coursework and not yet taking the exam. The Administrative Nurse verified the staff member had no dietary manager certification, and no policy regarding a certified dietary manager was provided.
Incomplete PBJ Staffing Reporting: The facility failed to submit accurate direct care staffing data to CMS through PBJ. The PBJ report showed extremely low weekend staffing, but review of the facility’s work schedules showed the same staffing pattern on weekends as during the week, including nurses, nurse aides, and a medication aide on multiple shifts. An admin staff member stated she was unsure why the weekend staffing was reported so low and was not sure whether her hours were included in PBJ tracking.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
The facility did not employ a full-time certified dietary manager for its 25 residents, risking inadequate nutrition. Dietary Staff BB, who was overseeing meal preparation, lacked the necessary certification, as confirmed by Administrative Nurse D. The facility's policy required a qualified nutritional professional if a dietitian was not full-time, which was not met.
The facility failed to ensure a sanitary environment by not monitoring washing machine temperatures, crucial for eliminating infectious pathogens. Staff interviews revealed confusion over responsibilities, with neither laundry nor maintenance staff checking temperatures. This non-compliance with facility policy placed residents at risk of infection.
The facility failed to provide written notice to residents or their representatives and did not notify the LTCO when residents were transferred to the hospital. This deficiency affected four residents, each transferred without the required notifications, placing them at risk of uninformed care choices and impaired rights.
A resident with a history of constipation was not provided with a comprehensive care plan to prevent constipation, despite having a diagnosis and frequent bowel incontinence. The care plan lacked specific interventions, leading to severe constipation and hospital admission. Observations and interviews confirmed the absence of necessary interventions, violating the facility's policy for comprehensive care plans.
The facility's Consultant Pharmacist failed to identify and report medication irregularities for several residents, including inappropriate indications for antipsychotic medication and the absence of stop dates for antianxiety medications. This oversight placed residents at risk for unnecessary medication side effects.
The facility failed to ensure appropriate indications and documentation for psychotropic medications for several residents, leading to deficiencies in medication management. A resident with dementia and other mental health issues received antipsychotic and antianxiety medications without documented nonpharmacological interventions or a risk versus benefit analysis. Another resident with depression received lorazepam without a required stop date, and a third resident with anxiety had a similar issue with Ativan. Staff were aware of the requirements but faced challenges in obtaining compliance from physicians.
A resident on a pureed diet did not receive a complete meal as the dietary staff failed to prepare and offer pureed bread, believing it would be soggy and unappetizing. This decision was made without the necessary approval from a physician or clinical dietician, violating the facility's policy and placing the resident at risk for impaired nutrition.
A resident received ten times the prescribed dose of metolazone due to a misreading of the handwritten order by a nurse. The error was compounded by the failure to use the EMR template and ignoring dose warnings. The resident was hospitalized for critically low potassium levels as a result.
Infection Control Failures in Respiratory Equipment Storage, Linen Handling, and Hand Hygiene
Penalty
Summary
The facility failed to ensure that resident respiratory equipment was stored in a sanitary manner when not in use. On multiple observations, R2’s CPAP mask was found lying on his bed or bedside table rather than in a sanitary container. R3’s nebulizer mask was observed on her bedside table and her nasal cannula was observed lying on her bed. R32’s oxygen nasal cannula was observed wrapped around her oxygen canister and later around the handle of her oxygen concentrator and portable oxygen tank, rather than being stored in a sanitary container. Administrative Nurse D stated that nebulizer pieces should be washed and stored in a plastic bag with the resident’s name and date, that CPAP masks should be placed in a compartment in the CPAP machine after each use, and that nasal cannulas should have dated bags connected to the resident’s chair or canister. The facility also failed to ensure clean laundry was transported in a sanitary manner and staff performed adequate hand hygiene. Housekeeping and laundry staff were observed carrying clean linens and shirts down the hall uncovered or in their arms next to their clothing, including a comforter with bedding, a gray long-sleeve shirt, and two shirts on hangers placed on top of a pink laundry bin outside the dirty utility room. During incontinent care for R14, CNA M handled wet slacks, retrieved clothing from the dresser, assisted with dressing and transfer, and touched the gait belt and shirt without washing hands; R14 and CNA R did not wash their hands. CNA M later confirmed she did not wash her hands or have R14 wash her hands and stated she should have done so after incontinent care and when leaving the room.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for the 28 residents who received meals from the facility kitchen. On 04/28/26, the noon meal was observed to consist of beef enchiladas, Spanish rice, and cheesecake, and Dietary Staff BB was observed in the kitchen overseeing preparation of the meal. On 04/27/26 at 07:35 AM, DS BB stated she was not a Certified Dietary Manager and said she had enrolled in and completed classes but had not taken the test. On 04/29/26 at 10:00 AM, the Administrative Nurse verified that DS BB did not have dietary manager certification, although she had enrolled in the dietary certification course and had not yet taken the test. Upon request, the facility did not provide a policy regarding a certified dietary manager.
Incomplete PBJ Staffing Reporting
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through Payroll Based Journaling (PBJ). The PBJ Staffing Data Report for FY 2026 Q1 documented excessively low weekend staffing, even though review of the facility’s actual working schedule sheets from 11/01/25 to 04/01/26 showed the same staffing pattern on weekends as during the week, including one nurse for day shift, one nurse for evening and night shift, two to three nurse aides on day shift, two nurse aides on evening and night shift, and one medication aide on day and evening shift. The revised Facility Assessment dated 12/10/25 documented that the specific needs of each resident in the community were identified and that staffing was adjusted as needed, with staffing listed for each shift. It included one licensed nurse for day shift and one licensed nurse for evening shift, one medication aide on day and evening shift, two to three nurse aides on day shift, and two nurse aides on evening and night shift. On 04/21/26, Administrative Staff A stated she was unsure why the facility showed extremely low weekend staffing on the PBJ, said she had worked weekends as a nurse aide and as the charge nurse, and was not sure whether her hours were reported in the PBJ data tracking. She also stated a nurse had quit during the time the PBJ showed extremely low weekend staffing.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for its 25 residents, which placed them at risk for inadequate nutrition. During an observation of the noon meal preparation, it was noted that Dietary Staff BB was overseeing the process. However, upon further inquiry, it was confirmed that Dietary Staff BB was not a certified dietary manager, although he had started taking the necessary classes. This lack of certification was verified by Administrative Nurse D. The facility's Food Service Staffing Policy, revised in October 2023, required that if a dietitian was not employed full-time, another qualified nutritional professional should serve as the dietary manager. This individual must meet specific qualifications, such as being a certified dietary manager or having equivalent credentials or experience. The facility's failure to adhere to this policy by not employing a qualified dietary manager compromised the nutritional services provided to the residents.
Inadequate Laundry Practices Risk Infection Spread
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases and infections due to inadequate laundry practices. Observations revealed that staff did not monitor or record the washing machine water temperatures, which is crucial for eliminating infectious pathogens. Housekeeping staff indicated that the facility had high-temperature washing machines, but the laundry staff did not check or record the hot water temperatures. Additionally, clothing and bedding from residents on Enhanced Barrier Precautions were washed with other residents' laundry, potentially increasing the risk of infection spread. Interviews with staff highlighted a lack of clarity regarding responsibilities for monitoring washing machine temperatures. The Administrative Nurse stated that either laundry or maintenance staff should be checking and recording these temperatures daily. However, the Maintenance Staff confirmed that he did not check the washing machine's hot water temperatures, focusing instead on monitoring waterborne pathogens in other areas. The facility's policy required handling all laundry as contaminated and specified temperature guidelines for effective pathogen elimination, which were not adhered to, placing residents at risk of infection.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notice to residents or their representatives regarding facility-initiated transfers to the hospital, as well as failing to notify the Office of the Long-Term Care Ombudsman (LTCO). This deficiency was identified for four residents, each of whom was transferred to the hospital without the required notifications. The facility's policy, dated October 2022, mandates that residents and/or their representatives receive written notice of the reason for transfer or discharge, and a copy of this notice should be sent to the LTCO. However, this policy was not followed in the cases of the residents reviewed. Resident 16, who had multiple medical conditions including atrial fibrillation and heart failure, was transferred to the hospital without written notice being provided to her or her representative, nor was the LTCO notified. Similarly, Resident 24, with severe cognitive impairment and a history of falls, was also transferred without the required notifications. In both cases, the facility's failure to adhere to its own policy placed the residents at risk of uninformed care choices and impaired rights. Additionally, Resident 4, who had intact cognition and a history of chest pain, and Resident 26, who was independent with most activities of daily living, were transferred to the hospital without written notice to them or their representatives, and without notifying the LTCO. The facility's administrative nurse and social service designee confirmed the lack of notification, citing unawareness of the requirement. This systemic failure to provide necessary notifications highlights a significant deficiency in the facility's adherence to regulatory requirements.
Failure to Develop Comprehensive Care Plan for Constipation Prevention
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of constipation, which led to a deficiency in care. The resident, who had a diagnosis of constipation and was frequently incontinent of bowel, had a care plan that lacked specific interventions to prevent constipation. Despite having intact cognition and being independent with most activities of daily living, the resident experienced severe constipation, which was documented in progress notes. These notes indicated that the resident had difficulty having bowel movements, requested stool softeners, and experienced severe straining with small rectal bleeding, ultimately leading to hospital admission for constipation and hypotension. Observations and interviews with administrative nurses confirmed the absence of necessary interventions in the resident's care plan to address constipation. The facility's policy required comprehensive care plans with measurable objectives and time frames to meet residents' needs, but this was not adhered to in the case of the resident. The lack of a detailed care plan placed the resident at risk for impaired care due to uncommunicated care needs, as evidenced by the resident's hospitalization for constipation.
Consultant Pharmacist Fails to Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for several residents, leading to deficiencies in medication management. Specifically, the CP did not report the inappropriate indication for Seroquel, an antipsychotic medication, prescribed to a resident with dementia and other behavioral disturbances. The resident's electronic medical record lacked documentation of a physical rationale, including unsuccessful attempts for nonpharmacological symptom management and a risk versus benefit analysis for the continued use of Seroquel. Additionally, the CP failed to address the absence of a stop date for the resident's as-needed lorazepam, an antianxiety medication, despite the physician's refusal to include one. Another resident with diagnoses of depression and adjustment disorder was prescribed lorazepam as needed for anxiety and restlessness, but the order lacked a stop date. The CP's drug regimen reviews over several months did not address this issue. Interviews with facility staff revealed awareness of the requirement for a stop date, but the physician did not comply, and the CP did not document this omission in the monthly reviews. This oversight placed the resident at risk for inappropriate use of antianxiety medication. A third resident with an anxiety disorder was prescribed Ativan, another form of lorazepam, with an indefinite stop date. The CP's regimen reviews from May to September did not identify or report the lack of a stop date or specified duration for the medication. The facility was unable to provide a policy regarding CP regimen reviews, indicating a systemic failure to ensure proper medication management and oversight, which placed residents at risk for unnecessary medication side effects.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure appropriate indications and documentation for the use of psychotropic medications for several residents, leading to deficiencies in medication management. Resident 19, who had diagnoses of dementia, anxiety, depression, and bipolar disorder, was receiving antipsychotic and antianxiety medications without documented unsuccessful attempts for nonpharmacological interventions or a risk versus benefit analysis. The physician's order for lorazepam lacked a 14-day stop date, which is required by the facility's policy. Observations revealed that Resident 19 frequently yelled out, and staff were aware of the need for a stop date but were unable to obtain one from the physician. Similarly, Resident 7, with diagnoses of depression and adjustment disorder, was receiving lorazepam without a stop date. The resident's care plan included monitoring for side effects and behaviors, but the physician's order did not comply with the facility's policy of limiting PRN orders to 14 days. Staff acknowledged the requirement for a stop date but faced challenges in getting the physician to comply. The lack of a stop date for the PRN lorazepam placed the resident at risk for adverse side effects. Resident 23, diagnosed with an anxiety disorder, also had a physician's order for PRN Ativan without a stop date. The facility's policy mandates a 14-day limit on PRN orders for antianxiety medications unless extended with proper documentation. Administrative staff confirmed the absence of a stop date and the difficulty in obtaining one from the physician. This oversight in medication management placed Resident 23 at risk for unnecessary psychotropic medication use.
Failure to Provide Complete Pureed Diet
Penalty
Summary
The facility failed to provide a nourishing, well-balanced diet to a resident who was on a pureed diet. During an observation, it was noted that the dietary staff prepared a pureed meal for the resident by blending a slice of meatloaf and mixed vegetables to the consistency of mashed potatoes. However, the dietary staff did not prepare or offer pureed bread to the resident, as they believed the resident would not eat it due to its soggy texture. This decision was made without approval from a physician or clinical dietician, as required by the facility's Therapeutic Diets Policy. The facility's policy, revised in October 2023, mandates that residents on therapeutic diets should not receive modifications that are not part of the diet unless approved by a physician in conjunction with a clinical dietician. The failure to provide the pureed bread, which is part of the grain group, resulted in the resident not receiving a complete and balanced meal, placing them at risk for impaired nutrition. This deficiency was identified through observation, record review, and interviews with dietary staff.
Significant Medication Error Due to Misreading of Prescription
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors. The resident returned from a cardiology appointment with a new order for metolazone, a diuretic, at a dose of 2.5 mg. However, Licensed Nurse (LN) G misread the order as 25 mg and instructed LN H to administer five 5 mg tablets from the resident's PRN stock. This resulted in the resident receiving ten times the prescribed dose. When the pharmacy delivered the correct medication dose of 2.5 mg a few hours later, LN G realized the error and contacted the resident's cardiologist. The cardiologist ordered monitoring for depleted fluid volume and a basic metabolic panel (BMP) the next day. The BMP revealed critically low potassium levels, leading to the resident's hospitalization for intravenous fluids and potassium supplementation. The resident's potassium levels remained critically low for several days, necessitating continued medical intervention. The root cause analysis identified that LN G incorrectly read the handwritten order and did not use the electronic medical record (EMR) template, which would have provided an alert for the excessive dose. Additionally, LN H, who administered the medication, did not notice the dose warning in the EMR. Both nurses failed to wait for the pharmacy to deliver the correct medication, opting instead to use the resident's PRN stock, which contributed to the significant medication error.
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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 Onaga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westy Community Care Home | 15.3 mi | ★★★★★ | 0 | 0 |
| Eastridge | 16.2 mi | ★★★★★ | 14 | 1 |
| Frankfort Community Care Home | 19.4 mi | ★★★★★ | 20 | 1 |
| Good Samaritan Society - Valley Vista | 21.3 mi | ★★★★★ | 0 | 0 |
| Community Hospital Onaga Ltcu | 21.7 mi | ★★★★★ | 0 | 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.