Onion Creek Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Onion Creek Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Apr 5, 2025

  Based on observation, interview, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 14 residents at risk of pressure ulcers. The facility failed to ensure Resident #1 had interventions in place to prevent an Unstageable Pressure ulcer in the thoracic spine (thoracic spine is the middle section of your spine. It starts at the base of your neck and ends at the bottom of your ribs). […]

• Immediate jeopardy, isolatedF689Feb 19, 2025

  Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not leave the facility with nursing staff being aware as she was found approximately 2.5 hours later and approximately 4.2 miles away (at a store off a major highway - 65 MPH) after being contacted by an outside party 02/16/25. The temperature was approximately 58 degrees. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/18/25 at 2:16 PM and an IJ template was given. […]

• Actual harm, patternF684Oct 2, 2024

  Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to implement orders from the hospital for blood glucose monitoring four times a day and administering of a sliding scale insulin four times a day upon Resident #1's admission on 09/16/24. […]

• Actual harm, isolatedF689Aug 11, 2026

  Based on observation, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents reviewed for accidents (Resident #1).This resulted in Resident #1 having a fall from her bed during peri-care which resulted in an acute fracture to the right tibial metaphysis on 07/08/2026.The noncompliance was identified as PNC. The noncompliance began on 07/08/2026 and ended on 07/16/2026. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of accidents and serious injuries. […]

• No harm, potential for more than minimal, widespreadF576May 16, 2025

  Based on interview, and record review, the facility failed to ensure residents had the right to send and receive mail for 7 of 7 confidential residents reviewed for right to communication. The facility failed to ensure residents received their mail on the weekend. This failure could put residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings included: During a confidential group interview on 5/14/2025 at 11:00 am., 7 of 7 residents said mail was not being distributed on the weekend. They indicated they were unsure why mail was not delivered by the weekend staff. […]