Onaga Operator, LLC

In the surveyor’s words

From the most serious findings on record at Onaga Operator, LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF609Dec 7, 2023

  The 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. […]

• Immediate jeopardy, isolatedF600Jul 28, 2025

  The 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. […]

• Immediate jeopardy, isolatedF760Mar 13, 2024

  The 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. […]

• Immediate jeopardy, isolatedF604Dec 7, 2023

  The 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. […]

• Immediate jeopardy, isolatedF760Nov 21, 2022

  The facility identified a census of 30 residents. The sample included three residents reviewed for medication errors. Based on observations, record review, and interviews, the facility failed to prevent a significant medication error for Resident (R) 1 when facility staff prepared and wrongly administered R2's medications, including psychotropic (any drug that affects brain activities associated with mental processes and behavior) and antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications, to R1 on 11/16/22. Certified Medication Aide (CMA) R prepared R1's medications, then realized R1 was in the shower. CMA R labeled the medication cup with R1's name, placed the cup back in the cart, and began to prepare R2's medications. […]