All citations for Onaga Operator, LLC
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
April 30, 2026
Showing 1 to 18 of 18 citations
Immediate jeopardy to resident health or safety
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Past non-compliance: already corrected by the time of the inspection (November 16, 2023).
Immediate jeopardy to resident health or safety
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Past non-compliance: already corrected by the time of the inspection (July 11, 2025).
Immediate jeopardy to resident health or safety
Ensure that residents are free from significant medication errors.
Past non-compliance: already corrected by the time of the inspection (February 13, 2024).
Immediate jeopardy to resident health or safety
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Past non-compliance: already corrected by the time of the inspection (November 16, 2023).
No harm, with potential for more than minimal harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
The home gave a date the problem would be corrected (November 1, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (November 1, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (May 29, 2026).
No harm, with potential for more than minimal harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
The home gave a date the problem would be corrected (November 1, 2024).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
The home gave a date the problem would be corrected (November 1, 2024).
No harm, with potential for more than minimal harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
The home gave a date the problem would be corrected (November 1, 2024).
No harm, with potential for more than minimal harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
The home gave a date the problem would be corrected (November 1, 2024).
No harm, with potential for more than minimal harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
The home gave a date the problem would be corrected (November 1, 2024).
No harm, with potential for more than minimal harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
The home gave a date the problem would be corrected (May 15, 2023).
No harm, with potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
The home gave a date the problem would be corrected (May 15, 2023).
No harm, with potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (May 15, 2023).
No harm, with potential for more than minimal harm
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
The home gave a date the problem would be corrected (May 15, 2023).
No harm, with potential for minimal harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
The home gave a date the problem would be corrected (May 29, 2026).
No harm, with potential for minimal harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
The home gave a date the problem would be corrected (May 29, 2026).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.