Onyx Wellness Center

In the surveyor’s words

From the most serious findings on record at Onyx Wellness Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Mar 5, 2026

  Based on review of facility policies, drug manufacture's information, interview with resident, and staff interviews, it was determined the facility failed to ensure a newly admitted resident diagnosed with End-Stage Renal Disease (ESRD) and a kidney transplant recipient received life sustaining medication. This failure resulted in the resident missing a total of eight doses of the medication Tacrolimus 0.5 milligrams, which led to critical laboratory values and placed the resident in an Immediate Jeopardy situation of organ rejection for Resident 119. […]

• Immediate jeopardy, isolatedF600Jan 31, 2024

  Based on review of facility policy, review of facility documentation, review of clinical records, review of video footage and interviews with staff, it was determined that the facility failed to ensure that one of six residents reviewed were free from physical abuse from nursing staff. This failure resulted in an Immediate Jeopardy situation with Resident R2 who was struck twice, and rough handled sustaining left upper arm bruising. (Resident R2). Findings Include: Review of facility policy on Abuse Prevention Program dated August 2020 states, The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. […]

• Immediate jeopardy, isolatedF689May 16, 2023

  Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to serve hot beverages with the appropriate lid and failure to monitor the temperature of hot water beverages served to residents. This failure resulted in Immediate Jeopardy situation to Resident R1 who spilled a hot water beverage and sustained an abdominal burn injury, for one of six residents reviewed. (Resident R1) Findings include: Review of undated facility policy Hot Liquid Management revealed the intention of the policy was to minimize the risk for resident burns caused by hot liquids. […]

• Actual harm, isolatedF689Mar 5, 2026

  Based on review of clinical records, facility documentation, and interview with staff, it was determined the facility failed to ensure a resident's snack bin was not in a location easily accessible to resident, which resulted in actual harm to Resident R87, while trying to obtain snacks, fell out of bed sustaining a laceration to the head, requiring two sutures and multiple steri-strips for one of two residents reviewed for falls (Resident R87). This deficiency was cited as past non compliance. Findings include: Review of facility policy Fall prevention, dated 2022, revealed the facility will implement fall prevention protocol as determined by resident's needs. […]

• Actual harm, isolatedF689Jan 21, 2025

  Based on review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to ensure adequate supervision of two staff members was provided during incontinence care to Resident R1. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip for one of seven residents reviewed. (Resident R1) Findings include: Review of facility policy titled Turning and Positioning, revised 2024, revealed assistance must be obtained in turning and repositioning residents/patients who require more than one-person assistance. Do not attempt to turn and reposition by yourself. […]