Onaga Operator, LLC
500 Western Street · Onaga, KS · 66521 · 7858894227
45 certified beds For profit - Limited Liability company Chain: Mission Health Communities
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Federal penalties on record: $24,845 in fines in the last 24 months.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
3 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.78 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.48 | 0.55–0.75 |
| Weekend hours / resident-day | 3.35 | ≈ weekday level |
| Nursing turnover / year | 43% | median 45% |
| Fines (3-yr window) | 3 · $51,274 |
Inspection citations (20 in the current record)
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Immediate jeopardy · J July 28, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 11, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E October 2, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected November 1, 2024 · Resident Rights
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Potential for harm · D October 2, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 1, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 2, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected November 1, 2024 · Pharmacy Service
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Potential for harm · D October 2, 2024
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.
Corrected November 1, 2024 · Pharmacy Service
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Potential for harm · F October 2, 2024
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.
Corrected November 1, 2024 · Nutrition and Dietary
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Potential for harm · D October 2, 2024
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.
Corrected November 1, 2024 · Nutrition and Dietary
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Potential for harm · F October 2, 2024
Provide and implement an infection prevention and control program.
Corrected November 1, 2024 · Infection Control
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Immediate jeopardy · J March 13, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected February 13, 2024 · Pharmacy Service
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Immediate jeopardy · J December 7, 2023 · found via complaint
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected November 16, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · L December 7, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 16, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 5, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected May 15, 2023 · Resident Rights
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Potential for harm · D April 5, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 15, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 5, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 15, 2023 · Quality of Life and Care
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Potential for harm · D April 5, 2023
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.
Corrected May 15, 2023 · Nursing and Physician Services
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Potential for harm · E September 15, 2021
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.
Corrected October 15, 2021 · Resident Rights
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Potential for harm · D September 15, 2021
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected October 15, 2021 · Resident Assessment and Care Planning
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Potential for harm · D September 15, 2021
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 15, 2021 · Quality of Life and Care
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Potential for harm · D September 15, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 15, 2021 · Quality of Life and Care
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Potential for harm · D September 15, 2021
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.
Corrected October 15, 2021 · Pharmacy Service
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 28, 2025 | Fine | $24,845 |
| March 13, 2024 | Fine | $14,518 |
| December 7, 2023 | Fine | $11,911 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 175220 · certified since April 1, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.