Onyx Care of Jena

Inspectors wroteBased on interview and record review the facility failed to ensure the Medical Director participated in the Quality Assessment and Assurance Process Quarterly meetings. Total sample size 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to practice Enhanced Barrier Precautions for 5 (Resident #7, Resident #17, Resident #31, Resident #34, and Resident #73) of 41 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, by failing to honor 1(Resident #10) of 1 sampled resident's choices.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care that met professional standards of quality care for 1 (Resident #78) of 1 sampled residents.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure the Comprehensive Resident Centered Plan of Care was revised to include behaviors for 1 (Resident #31) of 41 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (Resident #8 and Resident #26) sampled residents. The facility failed to: provide nail care for Resident #8; andprovide hair care for Resident #26.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #17) of 1 resident reviewed for respiratory care in a total sample of 41 residents. The facility failed to ensure respiratory equipment was properly changed, labeled, and stored.

Inspectors wroteBased on record review and interviews, the facility failed to provide pharmaceutical services that ensure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident. The facility failed to provide medications and/or biologicals to meet the needs of residents for 1 (Resident #59) of 1 resident reviewed for pharmaceutical services in a total sample of 41 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the physician was notified of a change in condition for 1 (#3) of 4 sampled residents when Resident #3 experienced severe pain but no pain medication was available to administer. This deficient practice resulted in an actual harm on 04/02/2026 at 6:23 p.m. when Resident #3 was admitted with a diagnosis of ORIF to both Left Femur and Right Wrist on 03/25/2026. admission orders included Hydrocodone 10/325mg by mouth every 6 hours as needed for pain. At that time Resident #3 complained of leg pain at a level of 6 out of 10, indicating severe pain per facility parameters, and was unable to receive any pain medication because the facility had not acquired her pain medication from the pharmacy. The nurse caring for Resident #3 failed to notify the physician that pain medication was unavailable for Resident #3.

Inspectors wroteBased on interviews and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, for 1 (Resident #3) of 4 residents reviewed for pain. This deficient practice resulted in an actual harm for Resident #3 on 04/02/2026 at 6:23 p.m., when the resident was admitted with an order for Hydrocodone 10/325 MG every 6 hours as needed for pain, and did not receive any pain medication. Resident #3 had diagnoses of status post ORIF to Left Femur fracture on 03/25/2026 and, ORIF of Right Wrist fracture on 03/25/2026 and pain. [...]

Inspectors wroteBased on interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident's representative, for 1 (Resident #3) of 4 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a copy of the written notice of discharge was sent to the Office of the State Long-Term Care Ombudsman for Resident 1 (#1) of 1 residents reviewed for facility-initiated discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were accurately documented on the TAR (Treatment Administration Record) for 1 (Resident #4) of 7 sampled residents. The facility had a total census of 73 residents according to the Resident List Report provided by the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the Nurse Practitioner (NP) of a resident's change in condition of an elevated heart rate for 1 (Resident #5) of 7 sampled residents. The facility census was 73.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) registry verification was obtained prior to re-hire for 1 (S9 CNA) of 2 (S9 CNA and S10 CNA) personnel records reviewed.

Inspectors wroteObservation on 03/18/2026 at 8:45 a.m. revealed a form for Daily Nursing Staff Posting dated 03/18/2026 was posted on a bulletin board in the middle of the facility. The resident census at start of shift, daily staffing hours required, or the actual hours worked were not posted on the form. Observation on 03/18/2026 at 8:45 a.m. also revealed a form for Daily Nursing Staff Posting dated 03/17/2026 that did not have resident census at start of shift, daily staffing hours required, or the actual hours worked documented on the forms or updated from the previous day. In an interview on 03/18/2026 at 9:20 a.m. with S4 SDC RN to review 03/17/2026 and 03/18/2026 Daily Nursing Staff Posting forms, S4 SDC RN confirmed the facility did not post the resident census, daily nursing hours required, or the actual nursing hours provided. [...]

Inspectors wroteReview of the facility's policy titled Enhanced Barrier Precautions with a review date of 03/01/2026 revealed in part, Enhanced Barrier Precautions (EBP) is an approach of gown and glove use during high contact resident care activities. Examples of high contact resident care activities.wound care. Review of Resident #2's record revealed in part an admit date of 09/03/2025, a primary diagnosis of Acute Respiratory Failure with Hypoxia, an order dated 09/19/2025 for Enhanced Barrier Precautions, and a Care Plan item dated 09/15/2025 for enhanced barrier precautions. Observation on 03/16/20026 at 2:25 p.m. of Resident #2's wound care by S6 TXRN revealed that S6 TXRN failed to follow EBP protocol. S6 TXRN did not wear a gown and change her gloves between cleaning and applying ointments and powder to the wounds for Resident #2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (Resident #2 and Resident #3) of 3 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 sampled residents.

Inspectors wroteBased on observations, record review, and interviews the facility failed to develop and implement a person-centered care plan for each resident to maintain the resident's highest practicable physical, mental, and psychosical well-being. The facility failed to: 1. Ensure staff placed, connected, and ensured proper functioning of Resident #122's bed alarm, as ordered; 2. Develop a comprehensive person-centered care plan for Resident #19; and Resident #30 There were 29 sampled residents.

Inspectors wroteResident #172 Review of the Facility's policy dated 11/2017 titled Weekly Skin Audit read in part .Policy: A skin audit will be documented on resident weekly. Any identified skin conditions will be documented and treatment initiated. Procedure: 1. Every resident will have a head to toe skin evaluation performed and documented on a weekly basis. Review of Resident #172 medical record revealed an admit date of 02/11/2025 with diagnoses that included: COPD, Congestive Heart Failure, Atherosclerotic Heart Disease, Depression, and Essential HTN. Review of Resident #172 Care plan with a review date of 05/20/2025 read in part . Risk for impaired skin integrity related to impaired mobility with interventions for weekly skin audits. Review of Resident #172 skin assessment dated [DATE] by S10 TX Nurse revealed 3 scabs to forehead area. No bruises noted. Interview on 06/04/2025 at 9:15 a.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse for 1 (#51) of 4 (#31, #50, #51, and #172) sampled residents investigated for abuse. The facility failed to protect Resident #51 from physical abuse by Resident #272. This failed practice resulted in an actual harm for Resident #51 on 05/20/2025 at 4:09 p.m. when Resident #272 hit Resident #51 multiple times on the head, causing lacerations to Resident #51's left cheek, right cheek, forehead, and chin.

Inspectors wroteBased on record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, for 1 (#34) of 6 (#16, #21, #28, #34, #49, and #122) residents sampled for Unnecessary Medications.

Inspectors wroteBased on record review and interview the facility failed to ensure an injury of unknown origin and allegation of abuse was reported immediately to management staff for 2 (#50 and #172) of 30 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 3 (#34, #51, and #60) of 5 (#16, #34, #44, #51, and #60) residents sampled for review of resident vaccinations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to: 1. Perform AM care including face/hair washing and shaving for Resident # 38; and 2. Provide daily bed baths for 2 (Resident #26 and Resident #34) residents. The total Sample Size is 29 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary services to maintain optimal skin integrity for 1 (Resident # 26) of 29 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#25) of 3 (#25, #53, and #122) residents reviewed for tube feeding.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review and provide regular in-service education based on the outcome of the annual performance reviews for 2 (S16 CNA and S17 CNA) of 3 (S13 CNA, S16 CNA, S17 CNA) certified nursing assistants reviewed for sufficient and competent nurse who required it.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure: 1. Facility staff wore a gown while administering medications to a resident on EBP, Resident #122, through a Gastrostomy (PEG tube); 2. Standard Precautions were utilized during wound care, 3. Unused resident care items were not stored on the floor 4. Resident's used basins were not stored in a shower 5. Resident's used urinal was not stored in a shower, and 6. A Curtain in the shower area was not visibly soiled.

Inspectors wroteBased on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 5 (#1, #2, #3, #4, & R1) of 13 (#1-#12 & #R1) sampled residents out of a total census of 74 residents. The facility failed to ensure controlled medications were administered as ordered and documented correctly. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record review and interview, the facility failed to ensure pain management was provided to residents by failing to assess for pain medication effectiveness after administration for 5 (#1, #2, #3, #4, and #R1) of 5 sampled residents reviewed for pain.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #11) of 2 ( Resident #11 and Resident #12) residents reviewed for abuse. The facility failed to ensure Resident #11 was not physically abused by Resident #12. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (#1) of 12 (#1-#12) sampled residents reviewed for quality of care. The facility failed to transport Resident #1 to an orthopedic specialist appointment in a timely manner as ordered.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) sampled residents. The facility failed to ensure Resident #4 was not physically abused by Resident #3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a PEG tube maintained acceptable parameters of nutritional and hydration status consistent with the resident's comprehensive assessment for 1 (#2) of 8 (#2, #R1, #R2, #R3, #R4, #R5, #R6, and #R7) sampled residents who received nutrition and hydration via PEG tube. The total sample size was 12.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment. The facility failed to ensure: 1. The floor in Rooms a, b, and c were clean, sanitary and free of dust, trash and dead insects. 2. The ceiling tiles Rooms a and b were not loose with exposed insulation, and did not have brown stained and holes ceiling tiles were securely in place without exposed insulation and were clean without brown stains. 3. The over bed wall mounted lights were operational in Room b over both beds a and b; and 4. The window pane in Room a was cleaned and allowed resident to see the outside view.

Inspectors wroteBased on interviews and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #43) of 5 (Resident #10, Resident #43, Resident #45, Resident #56 and Resident #57) residents reviewed for unnecessary medication and 1 (Resident #268) of 1 resident reviewed for tube feeding. The facility failed to: 1. Ensure labs were obtained as ordered by the physician for Resident #43. 2. Notify the physician of a dietician's recommendation to meet the nutritional needs of Resident #268.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who were unable to carry out ADL's (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure Residents #1 and Resident #4 were free from facial hair and failed to provide nail care to dependent residents for Residents #11, Resident #17, Resident #21, Resident #38, Resident #48 and Resident #62 in a total sample of 10 residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #17) of 1 resident reviewed for dignity by failing to ensure a female resident was free of facial hair.

Inspectors wroteBased on record review and interview, the facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting for 1 (02/13/2024) of 3 (01/09/2024, 02/13/2024, and 03/14/2024) meetings reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure services were provided according to the resident's Comprehensive Plan of Care for 1 (Resident #268) of 1 (Resident #268) residents sampled for tube feeding. The facility failed to ensure Resident #268's nutritional needs were met.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the nurse staffing information was posted daily.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 3 (#11, #17, and #48) of 3 Residents who were ordered and served pureed diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. The facility failed to ensure all staff adhered to Enhanced Barrier Precautions for 1 (Resident #6) of 6 (Resident #6, Resident #56, Resident #59, Resident #218, Resident #268, and Resident #269) residents reviewed for infection control.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #5) of 7 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. This deficient practice resulted in an Actual Harm for Resident #5 on 02/05/2024 at 2:20 p.m., when Resident #6 hit Resident #5 in the left eye two times with a closed fist. Resident #5 received first-aid treatment in the facility for multiple abrasions and bruising to the face. Resident #5 was sent to a local emergency department where he received treatment for a left periorbital/facial contusion.

Inspectors wroteBased on interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident, and the resident's representative, for 1 (#7) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled Residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #7) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled Residents. The facility failed to ensure respiratory equipment was properly changed, labeled and contained.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of staff to resident verbal abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to have evidence that allegations of abuse were thoroughly investigated for 3 allegations of abuse involving 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to ensure Resident #5 had a bed alarm applied to prevent falls after sustaining a fall with major injury.