Onyx Care of Ruston

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 6 (#72, #75, #76, #91, #120, #124) of 6 residents reviewed for respiratory care. The facility failed to ensure:1). emergency tracheostomy supplies were available in resident rooms (#72, #124), 2). Oxygen concentrator filters were cleaned timely (#120), and 3). signage regarding oxygen in use was placed on resident doors (#75, #76, #91).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nursing staff implemented the physician's order for oxygen and nursing staff failed to perform a respiratory assessment before and after suctioning per competency for 1 (#72) of 6 residents reviewed for respiratory care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain infection control principles by staff not appropriately sanitizing hands during medication administration for 3 (#25, #63, #67) of 8 residents observed during medication administration and staff failed to use EBP during tracheostomy care and suctioning for 1 (#72) of 2 residents with tracheostomies.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principals.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident for 1 (#1) of 3 sampled residents reviewed for care plans.

Inspectors wroteBased on record review and interviews, the facility failed to maintain the door locking mechanism on an exterior door in the secured unit to prevent elopement from the secured unit for 1 (#1) of 3 (#1, #2, #3) residents reviewed. The deficient practice resulted in an immediate jeopardy for Resident #1 on 05/23/2025 at 11:07 a.m. when Resident #1 who was an elopement risk was able to exit the secured unit to the outside of the building through a door with a malfunctioning locking mechanism. Resident #1 was picked up on the two lane highway with a speed limit of 55 miles per hour approximately 0.2 miles from the facility by S8Housekeeper. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 05/29/2025, thus it was determined to be a past noncompliance citation.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents and accidents. The facility failed ensure a resident received supervision during a bed bath for 1 (#1) of 3 (#1, #2, #3) residents reviewed for falls. The deficient practice resulted in an immediate jeopardy for Resident #1 on 04/15/2025 at 10:00 a.m. when Resident #1 fell out of the left side of the bed during a bed bath when S3CNA (Certified Nursing Assistant) failed to ensure the resident was secured and safe in the bed to prevent him from falling before she turned away to retrieve Resident #1's clothing from the closet. S3CNA had removed Resident #1's fall mat from the left side of the bed to provide ADL (Activities of Daily Living) care and Resident #1 landed on the floor on his right side. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for any active bleeding or bruising for a resident who received an anticoagulant for 1 (#104) of 5 (#20, #33, #60, #96, and #104) residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by having wheelchairs in need of repair for 5 (#6, #7, #22, #32, #33) of 9 (#6, #7, #19, #22, #29, #32, #33, #80, #133) residents reviewed for environment.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents received services for reasonable accommodation of needs by failing to provide set-up assistance with meals for 1 (#26) of 1 residents reviewed for positioning and mobility.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (#29) of 9 (#6, #7, #19, #22, #29, #32, #33, #80, #133) residents reviewed for environment. The failed practice was evidenced by resident #29 not having bed linen on the bed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of discipline or convenience for 1 (#31) of 3 (#31, #53, and #96) residents reviewed for restraints. The facility failed to ensure that resident #31 was able to self-release his wheelchair seatbelt upon request which resulted in the failure to identify the seatbelt as a restraint.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a care plan had been revised for 1 (#31) of 3 (#31, #53, and #96) residents reviewed for restraints.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 1 (#20) of 2 (#20, #104) residents reviewed for ADL care. The facility failed to ensure that resident #20 had neatly groomed and shaved facial hair.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that nursing staff had the appropriate competencies and skills necessary to care for resident needs. The facility failed to obtain orders and document treatment performed to a tracheostomy stoma for 1 (#34) of 2 (#34 and #60) residents reviewed for wound care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was palatable, and served at an appetizing temperature.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free from misappropriation of resident property for 32 (#1-#32) of 32 representative sampled residents of 132 total residents identified with an active trust fund account since [DATE].

Inspectors wroteBased on record review and interview, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to one or more law enforcement entities for 1 (#1) of 1 sampled residents reviewed for misappropriation of resident funds.

Inspectors wroteBased on record review and interview the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 1 (#120) of 4 (#21, #63, #87 and #120) records reviewed for competent staff. The facility failed to ensure resident #120 received medications as ordered by the physician.

Inspectors wroteBased on observations and interviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by failing 1) to ensure the whirlpool room on the secured unit was clean, and 2) to ensure staff discarded contaminated items in a sanitary manner.

Inspectors wroteBased on record review and interview, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#123) of 41 residents reviewed in the initial pool screening for advanced directives.

Inspectors wroteBased on observation and interview the facility failed to provide personal privacy during incontinent care for 1 (#76) of 7 (#36, #38, #63, #76, #81, #88, #108) residents observed for incontinent care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. The facility failed to administer pain medication as needed to 1 (#437) of 1 (#437) sampled resident's reviewed for pain management.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to provide an environment free of accident hazards for 1 (#2) of 5 (#2, #4, #5, #6 and #7) residents identified at high risk for elopement. The facility failed to ensure all exit doors were secured to prevent residents at high risk for elopement from exiting the facility unsupervised. This deficient practice resulted in an Immediate Jeopardy situation on 10/22/2023 at approximately 1:15 a.m. when resident #2 (a severely cognitively impaired resident identified as an elopement risk) was found across the street in a neighbor's yard by a staff member. Resident #2 was located 50 minutes after she eloped on 10/22/2023 through an unsecured door and was returned to the facility at approximately 2:00 a.m. S1Administrator was notified of the Immediate Jeopardy on 10/30/2023 at 5:30 p.m. [...]

Inspectors wroteBased on observations, record reviews and interviews the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#2) of 5 (#2, #4, #5, #6 and #7) residents reviewed for elopement. The facility failed to: Have an effective system in place to ensure resident #2 (whom was at high risk for elopement, and wore a wander alert bracelet) was adequately supervised to prevent resident #2 from exiting the building through an unsecured door. The Administrator failed to ensure the facility's environment was free of accident hazards and resident #2 had increased monitoring after she eloped from the facility on 10/22/2023. This deficient practice resulted in an Immediate Jeopardy situation on 10/22/2023 at approximately 1:15 a.m. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to ensure resident received accommodation of needs for 1 (#5) out of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure Resident #5 was transported to a scheduled doctor's appointment.