Onyx Care of Jena

In the surveyor’s words

From the most serious findings on record at Onyx Care of Jena, in the surveyor’s own words.

• Actual harm, isolatedF580May 11, 2026

  Based on interviews and record review, the facility failed to ensure the physician was notified of a change in condition for 1 (#3) of 4 sampled residents when Resident #3 experienced severe pain but no pain medication was available to administer. This deficient practice resulted in an actual harm on 04/02/2026 at 6:23 p.m. when Resident #3 was admitted with a diagnosis of ORIF to both Left Femur and Right Wrist on 03/25/2026. admission orders included Hydrocodone 10/325mg by mouth every 6 hours as needed for pain. At that time Resident #3 complained of leg pain at a level of 6 out of 10, indicating severe pain per facility parameters, and was unable to receive any pain medication because the facility had not acquired her pain medication from the pharmacy. […]

• Actual harm, isolatedF697May 11, 2026

  Based on interviews and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, for 1 (Resident #3) of 4 residents reviewed for pain.This deficient practice resulted in an actual harm for Resident #3 on 04/02/2026 at 6:23 p.m., when the resident was admitted with an order for Hydrocodone 10/325 MG every 6 hours as needed for pain, and did not receive any pain medication. Resident #3 had diagnoses of status post ORIF to Left Femur fracture on 03/25/2026 and, ORIF of Right Wrist fracture on 03/25/2026 and pain. […]

• Actual harm, isolatedF600Feb 12, 2024

  Based 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 (Resident #5) of 7 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. This deficient practice resulted in an Actual Harm for Resident #5 on 02/05/2024 at 2:20 p.m., when Resident #6 hit Resident #5 in the left eye two times with a closed fist. Resident #5 received first-aid treatment in the facility for multiple abrasions and bruising to the face. Resident #5 was sent to a local emergency department where he received treatment for a left periorbital/facial contusion. […]

• Actual harm, isolatedF689Mar 28, 2022

  Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1(#10) resident reviewed for accidents out of a total of 34 sampled residents. This failed practice resulted in an actual harm situation for resident #10 on 01/11/2022 at approximately 1:50 p.m. when Resident #10, a cognitively impaired resident who resided on the Memory Unit, and required supervision when ambulating, fell when S4CNA and S5TempCNA turned away after standing Resident #10 up from her wheelchair. Resident #10 sustained a laceration above the left eyebrow area with active bleeding. […]

• No harm, potential for more than minimal, widespreadF882Mar 28, 2022

  Based on record review and interviews, the facility failed to ensure that the staff carrying out the Infection Control Program was qualified and completed specialized training in infection prevention and control (S23 IC Nurse). The total facility census was 69 residents. Findings: Interview with S1 Administrator on 03/21/2022 at 8:30 a.m. revealed S23 IC nurse was over the facility's Infection Control Program. Review of S23 IC nurse's personnel folder revealed she was not certified to oversee the facility's Infection Control and Prevention Program. S23 IC nurse had not completed specialized training in infection prevention and control. Interview with S2 DON on 03/22/2022 10:00 a.m. […]