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Deficiency Records for Onaga Operator, LLC
A list of the most recent deficiencies for Onaga Operator, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Onaga Operator, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-11-19 | 2024-12-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-02 | 2024-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-02 | 2024-11-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-10-02 | 2024-11-01 | N |
| 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. | Health | 2024-10-02 | 2024-11-01 | N |
| 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. | Health | 2024-10-02 | 2024-11-01 | N |
| 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. | Health | 2024-10-02 | 2024-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-02 | 2024-11-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-13 | 2024-02-13 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-07 | 2023-11-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-07 | 2023-11-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-22 | 2023-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-22 | 2023-06-16 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-22 | 2023-06-16 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-05-10 | 2023-05-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-10 | 2023-05-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-10 | 2023-05-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-10 | 2023-05-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-10 | 2023-05-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-10 | 2023-05-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-10 | 2023-05-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-05 | 2023-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-05-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-05 | 2023-05-15 | Y |
| 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. | Health | 2023-04-05 | 2023-05-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-21 | 2022-11-18 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-09-15 | 2021-10-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-15 | 2021-10-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-15 | 2021-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-15 | 2021-10-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-15 | 2021-10-15 | N |
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