Onaga Operator, LLC

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure Resident (R)2's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask, R3's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks and nasal cannula, and R32's nasal cannula were stored in a sanitary manner when not in use. The facility failed to ensure clean laundry was transported in a sanitary manner. The facility further failed to ensure staff performed adequate hand hygiene.

Inspectors wroteBased on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 28 residents who resided in the facility and received meals from the facility kitchen.

Inspectors wroteBased on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).

Inspectors wroteThe facility identified a census of 32 residents, with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to prevent sexual abuse when Resident (R)2 used topical pain medication as lubrication and penetrated cognitively impaired resident R1 anally and vaginally. On 07/11/25 at 03:05 PM, cognitively impaired R1 reported to LN G she felt nauseated, and LN G noted R1 to be anxious. R1 stated R2 utilized topical pain medication (Voltaren) during a sexual encounter, as lubrication, R1 felt sick, and reported hurting and bleeding. LN G asked R1 to clarify if it was used in her vagina or rectum, and R1 stated vagina. R1 reported R2 had put it on himself, and then it went in. R1 was unable to provide a date or time when the incident with R2 occurred, but stated it was a couple of days ago. [...]

Inspectors wroteThe facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 25 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections when staff failed to implement laundry practices to eliminate infectious pathogens. This placed the residents at risk of obtaining an infection or communicable disease.

Inspectors wroteThe facility had a census of 25 residents. The sample included 13 residents, with four reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notice for a facility-initiated transfer for Resident (R) 16, R24, R4, and R26 or their representatives when they were transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of R16, R24, R4, and R26's discharge. This placed the residents at risk for uninformed care choices and impaired rights.

Inspectors wroteThe facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with instruction to staff on providing interventions for the prevention of constipation (difficulty passing stools) for one resident, Resident (R) 26, who had a history of constipation and had been admitted to hospital for constipation. This placed R26 at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 25 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the inappropriate indication for Seroquel (an antipsychotic medication) for Resident (R)19 and failed to identify and report the lack of a stop date for R19, R7 and R23's as needed (PRN) lorazepam (an antianxiety medication). This placed the residents at risk for unnecessary psychotropic medication side effects.

Inspectors wroteThe facility had a census of 25 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate indication, or a documented physician rationale, which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of Resident (R) 19's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) and failed to ensure a 14-day stop date or specified duration for R19, R7 and R23s' ongoing as needed (PRN) antianxiety (a class of medications that calm an relax people with excessive anxiety, nervousness, or tension). This placed the residents at risk for unintended effects related to psychotropic (alters mood or thought) medications.

Inspectors wroteThe facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide a nourishing, well-balanced diet for one resident who received a pureed diet. This placed the resident at risk for impaired nutrition.

Inspectors wroteThe facility identified a census of 31 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free of significant medication errors. On 02/12/24 R1 returned to the facility from a cardiology appointment with a new order for metolazone, a diuretic (medication to promote the formation and excretion of urine), 2.5 milligrams (mg) that day, and another dose on 02/14/24. Licensed Nurse (LN) G incorrectly read the order as 25 mg and instructed LN H to administer five of R1's 5 mg metolazone from his PRN (as needed) stock. When the pharmacy delivered the medication to the facility a few hours later, LN G saw the dose was 2.5 mg. [...]

Inspectors wroteThe facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff identified an and reported immediately to the administrator an episode of abuse when staff manually restrained Resident (R)1 to administer medications. On 11/10/23 at around 06:30 PM Certified Medication Aid (CMA) R asked Certified Nurse Aide (CNA) M and CNA N to help administer eye ointment to R1. CMA R, CNA M, and CNA N went into R1's room and CMA R climbed on top of R1, straddled him, and pinned his arms under the blankets while R1 attempted to resist. CNA M told CMA R the actions were inappropriate, but CMA R ignored CNA M. Neither CNA M nor CNA N reported the incident at that time. [...]

Inspectors wroteThe facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from abuse including physical restraint when staff manually restrained Resident (R) 1 to administer medications. On 11/10/23 at around 06:30 PM, Certified Medication Aide (CMA) R asked Certified Nurse Aide (CNA) M and CNA N to help administer eye ointment to R1. CMA R, CNA M, and CNA N went into R1's room and CMA R climbed on top of R1, straddled him, and pinned his arms under the blankets while R1 attempted to resist. CNA M told CMA R the actions were inappropriate, but CMA R ignored CNA M. The facility staff failed to ensure R1 remained free from abuse when staff physically restrained him. This placed R1 in immediate jeopardy.

Inspectors wroteThe facility had a census of 30 residents with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide two of three sampled residents, Resident (R)17 and R26 (or their representative) the completed (SNF ABN) Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form 10055.

Inspectors wroteThe facility had a census of 30 resident and the sample included twelve. Based on observation, record review, and interview, the facility failed to prevent an incident of staff neglect for Resident (R) 7, when R7 slid out of bed on 03/11/23 and Administrative Nurse E failed to document and report the fall to other care staff so staff could provide follow up fall care. On 03/28/23, R7 was diagnosed with a right femur (thigh bone) fracture (broken bone), which was originally classified as an injury of unknown origin until the investigation revealed the resident had a fall which a staff member was aware of but neglected to document, notify the physician and family, and provide after fall care until after the injury was apparent.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide an environment free of accident hazards for Resident (R) 25 who smoked cigarettes. This placed R25 at risk for avoidable injuries and fire related hazards.

Inspectors wroteThe facility had a census of 30 resident and the sample included twelve residents. Based on observation, record review, and interview, the facility failed to ensure staff possessed the skills and knowledge necessary to identify and appropriately follow up on an unwitnessed fall from bed for Resident (R) 7. This failure placed R7 at risk for unidentified injuries and related pain, and delay in adequate diagnostics and treatment.