Onyx Care of Winnfield

Inspectors wroteBased on observation, record review, and interview, 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 infections. The facility failed to ensure the following:Resident room and living space were maintained in a clean and sanitary manner,Droplet precautions signage was posted for Resident #1,Shower rooms were maintained in a clean and sanitary manner,Proper staff training of chemicals used for cleaning and disinfection of environment,Proper staff training of handling soiled linen and waste,Necessary staff had access to chemicals used for cleaning and disinfection of environment, andImplement Enhanced Barrier Precautions for Resident #76. This deficient practice had the potential to affect all residents who reside in the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure reasonable accommodation of needs by failing to ensure a properly-fitting helmet was provided for 1 (Resident #25) of 42 sampled residents. Resident #25 Review of Resident #25's medical record revealed an admit date of 01/23/2025 with diagnoses that included: Nontraumatic Subarachnoid Hemorrhage, Generalized Anxiety Disorder, Diffuse Traumatic Brain Injury, Schizoaffective Disorder and Hypertension Review of Resident #25's Review of Resident #25's Care plan with review date of 02/04/2026 read in part. Resident #25 is at risk for injuries/falls. Ensure a protective helmet is worn when out of bed. Encourage use due to poor memory. Review of Resident #25's Quarterly MDS with ARD of 10/13/2025 revealed a BIMS of 06, indicating severe cognitive impairment. An observation on 01/12/2026 at 10:08 a.m. [...]

Inspectors wroteNumber of residents sampled:Number of residents cited:Review of facility policy titled, Notification of Change in a Resident's Status with a revision date of 11/2017 revealed in part. The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in the resident's condition, per standards of practice and Federal and/or State Regulations. Responsibility: All Nursing Personnel. Guideline for notification of physician/ responsible party (not all inclusive). d. Any accident or incident (per Federal and State regulation). Review of Resident #52's electronic health record revealed an admission date of 12/23/2024, with diagnoses that included, in part. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the SNF ABN Form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055) was provided to the resident and/or the resident's responsible party prior to the discontinuation of Medicare Part A services for 1 (Resident #31) of 1 resident reviewed for Beneficiary Notification who required the notification. Review of Resident #31's SNF Beneficiary Notification Review revealed Resident #31 was discharged from Medicare Part A services when benefit days were not exhausted. Further review revealed a SNF ABN Form CMS-10055 was not provided to the resident or their RP prior to discharge from the service. Interview with S9MDS on 01/14/2026 at 1:30 p.m. confirmed Resident #31 remained in the facility after being discharged from skilled services with benefit day remaining. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the privacy and confidentiality of medical records for 3 (Resident #23, Resident #45, and Resident #66) of 42 sampled residents. Resident #23 On 01/12/2026 at 9:20 a.m., observation of the facility outside dumpster area with S10Dietary revealed 3 medication blister packs on the ground with patient labels still fully intact. 1 of the 3 blister packs observed had Resident #23's name present and was labeled as Divalproex 125 milligram (mg) capsule. Resident #45 On 01/12/2026 at 9:20 a.m., observation of the facility outside dumpster area with S10Dietary revealed 3 empty medication blister packs on the ground with patient labels still fully intact. 2 of the 3 medication blister packs observed had Resident #45's name present and labeled as medications Naltrexone 50mg Tablet and Amlodipine 10mg tablet. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and homelike environment for 1 (#76) out of 3 residents sampled for environment. Observation of Resident #76's room on 01/12/2026 at 9:51 a.m. revealed the privacy curtain was visibly soiled with multiple black and brownish-orange stains. Observation of Resident #76's room on 01/12/2026 at 4:01 p.m. revealed the privacy curtain was visibly soiled with multiple black and brownish-orange stains. Interview with S15RN on 01/13/2026 at 9:12 a.m. revealed the facility did not have a general housekeeping policy. Observation of Resident #76's room on 01/13/2026 at 10:00 a.m. accompanied by S1ADM confirmed the privacy curtain was visibly soiled with multiple black and brownish-orange stains. S1ADM revealed she was unaware of the facility's policy regarding soiled privacy curtains. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 2 ( #57 and #58) of 3 (#6, #57, and #58) residents reviewed for ADL care. The facility failed to ensure:Resident #57 was provided nail care and was shaved; and Resident #58 was provided a bath on scheduled bath days.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 2 (#9 and #76) of 3 (#9, #52, and #76) residents reviewed for nutrition by:Failure to implement registered dietitian's recommendations for Resident #9; and Failure to provide tube feeding as ordered for Resident #76.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #76) of 4 residents reviewed for respiratory care. The facility failed to ensure:Oxygen was administered at the prescribed flow rate; andRespiratory equipment was appropriately labeled. Review of the facility's policy titled Oxygen Therapy revised 08/2014, revealed, in part. Oxygen therapy is to be provided under the direction of a written physician's order. Change tubing weekly. Date tube when changed (weekly). Review of Resident #76's EMR revealed an admission date of 08/21/2025 with diagnosis including COPD, Shortness of Breath, Diabetes, Dysphagia, Heart Failure, Acute Embolism and Thrombosis, and Hypotension of Hemodialysis. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles by failing to ensure that expired medications were not available for use/administration to residents.

Inspectors wroteBased on interview and record review the facility failed to promptly obtain and notify the NP (Nurse Practitioner) of ordered lab results for 1 (Resident #58) of 42 Sampled Residents.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 68 residents who received meals from the kitchen. The facility failed to ensure:1. Food items in the refrigerators and freezers were labeled, dated, and stored in a sanitary manner; and 2. Dry Food items were labeled with an open date and stored in a sealed container. On 01/12/2026 at 8:55 a.m., observation of the kitchen walk-in refrigerator revealed 1 bag of green onions opened and undated, 1 bag of shredded lettuce opened and undated, and 1 Activia yogurt opened with yogurt present on the packaging. On 01/12/2026 at 08:55 a.m., S10Dietary confirmed 1 bag of green onion and 1 bag of shredded lettuce should have been sealed and labeled with an open date, but were not. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage and refuse were properly disposed of. This deficient practice had the potential to affect all 71 residents at the facility. Review of facility undated policy titled Garbage and Rubbish Disposal read in part. Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen does not encourage infest or rodents. All outside dumpsters will be maintained in a clean and sanitary condition. Outdoor trash receptacles will be kept covered, and the surrounding area kept free of litter. On 01/12/2026 at 9:16 a.m., observation of the facility's outdoor dumpster area revealed a moderate amount of empty boxes outside of the dumpster area, a moderate amount of litter outside of the dumpster area, and the dumpster door was open. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (Resident #2) out of 3 (Resident #1, Resident #2, Resident #3) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's discharge was documented in the resident's medical record for 2 (Resident #1, Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The facility failed to:1. Ensure documentation in the medical record included the basis for discharge for Resident #1 and Resident #R1;2. Ensure documentation in the medical record included that written discharge instructions were given to and discussed with the Resident/Responsible Party for Resident #1 and Resident #R1; and3. Ensure documentation in the medical record included discharge planning that addressed caregiver support and referrals to local contact agencies for Resident #1.

Inspectors wroteBased on record review and interview, the facility failed to have a discharge summary that included the required information for 2 (Resident #1 and Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The discharge summaries for Resident #1 and Resident #R1 failed to include:1. A recapitulation of the residents' stay that included diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results;2. A final summary of the residents' status at the time of the discharge; and3. Reconciliation of all pre-discharge medications with the residents' post-discharge medications (both prescribed and over-the-counter).

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents sampled with behavioral health diagnoses by failing to: 1. Develop and implement a person-centered plan of care that addressed Resident #1's history of Substance Use/Abuse; 2. Ensure concerns identified in the provider's progress notes regarding drug diversion were addressed; and 3. Perform monthly UDS as ordered.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the admission and Quarterly MDS assessments accurately reflected a resident's status for 1 (Resident #1) of 5 sampled residents.

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 #1) of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide mental health services as dictated by accepted standards of quality for a resident admitted with multiple mental health diagnoses for 1 (Resident #1) of 5 sampled residents. The facility failed to: 1. Provide a timely referral for mental health services, and 2. Ensure mental health services were provided on a continual basis.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse, for 1 (#3) of 3 (#2, #3, and #5) residents reviewed for abuse. The facility failed to protect Resident #3 from physical abuse by Resident #5. 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 observation and interview the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure the nutritional adequacy of the meal for all residents who received a regular diet prepared by the facility kitchen.

Inspectors wroteBased on observation and interview the facility failed to store food in accordance with Professional standards for food safety. The facility failed to properly store dry food items in the kitchen as evidenced by one loaf of bread with mold present; two packages of hot dog buns that expired on 08/19/2024; one opened box of cornstarch that was undated and one used pad of butter in the refrigerator, unsealed and undated. This deficient practice had the potential to affect any resident who consumed meals served from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (#30) of 1 (#30) resident reviewed for environment. The facility failed to ensure Resident #30 had a call light in reach in order to call for assistance. The total sample size was 23.

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 (#76) of 2 ( #68 and #76) residents reviewed for abuse. The facility failed to ensure Resident #76 was not physically abused by Resident #68.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation of an incident of abuse for 1 (#76) of 2 (Resident #68 and Resident #76) residents sampled for abuse in a total sample of 23.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, by failing to implement appropriate interventions for weight loss for 1 (#56) of 2 (#32 & #56) residents reviewed for nutrition. The facility failed to: 1. Ensure Resident #56's meal intake was documented for each meal, as care planned, and 2. Provide one on one assistance to Resident #56 with all meals, as care planned.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that each resident was treated with respect and dignity and cared for in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#2) of 3 (#1, #2, & #3) sampled residents by failing to ensure she was free of facial hair.

Inspectors wroteBased on record review and interview the facility failed to implement the plan of care to meet the needs of 2 (#1 & #2) of 3 (#1, #2, & #3) sampled residents. The facility failed to monitor and record food intake at each meal as directed in the residents' care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored under proper temperature controls for 2 (Hall A medication refrigerator and Hall B medication refrigerator) of 2 medication refrigerators.

Inspectors wroteBased on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #80) of 1 sampled resident reviewed for resident assessments.

Inspectors wroteBased on interview and record review, the Facility failed to have an appropriate person-centered care plan for Resident #61 by failing to have interventions care planned when Resident #61 refused ADL (Activities of Daily Living) care or refused to allow staff to change his bed linen. Total sample size was 20.

Inspectors wroteBased on record review and interview, the facility failed to promptly notify the ordering physician of the results of a urine culture resulting in a delay of treatment for 1 (Resident #16) of 20 sampled residents.

Inspectors wroteBased on observation and interview the Facility failed to ensure garbage and refuse were disposed of properly.