Onion Creek Nursing And Rehabilitation Center

Penalties

• Apr 5, 2025 — Fine ($42,224)
• Feb 19, 2025 — Fine ($9,113)

Inspection findings

1. Jun 5, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 16, 2026 · CMS health inspection

2. Jan 28, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Mar 3, 2026 · CMS health inspection

3. Nov 5, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Dec 12, 2025 · CMS health inspection

4. Jul 3, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 26, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0685 Quality of Life and Care Deficiencies

     Assist a resident in gaining access to vision and hearing services.

     Corrected Jul 18, 2025 · CMS health inspection

5. Apr 5, 2025 Health · 1 finding
   • Serious Scope/severity K Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Apr 21, 2025 · CMS health inspection

6. Feb 19, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 5, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 5, 2025 · CMS health inspection

7. Oct 2, 2024 Health · 1 finding
   • Serious Scope/severity H Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Oct 3, 2024 · CMS health inspection

8. Jul 1, 2024 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 9, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 2, 2024 · CMS health inspection

9. Feb 29, 2024 Health · 7 findings
   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0808 Nutrition and Dietary Deficiencies

     Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Nov 12, 2024 · CMS fire safety

10. Dec 2, 2022 Health · 4 findings
    • Not serious Scope/severity D

      F0578 Resident Rights Deficiencies

      Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

      Corrected Dec 9, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Dec 9, 2022 · CMS health inspection

    • Not serious Scope/severity F

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Dec 9, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 9, 2022 · CMS health inspection

11. Sep 10, 2021 Health · 8 findings
    • Not serious Scope/severity E

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Sep 28, 2021 · CMS health inspection

    • Not serious Scope/severity D

      F0690 Quality of Life and Care Deficiencies

      Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

      Corrected Sep 28, 2021 · CMS health inspection

    • Not serious Scope/severity E

      F0756 Pharmacy Service Deficiencies

      Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

      Corrected Sep 28, 2021 · CMS health inspection

    • Not serious Scope/severity E

      F0758 Pharmacy Service Deficiencies

      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 Sep 28, 2021 · CMS health inspection

    • Not serious Scope/severity E

      F0761 Pharmacy Service Deficiencies

      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 Sep 28, 2021 · CMS health inspection

    • Not serious Scope/severity D

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Sep 28, 2021 · CMS health inspection

    • Not serious Scope/severity E

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Oct 1, 2021 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Oct 1, 2021 · CMS fire safety

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 01/18/2022
• COOPER, BRIAN — adp of the snf, NOT APPLICABLE, since 10/01/2022
• COOPER, BRIAN — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• COOPER, BRIAN — managing control - governing body, NOT APPLICABLE, since 10/01/2022
• HOOPER, GRADY — corporate officer, NOT APPLICABLE, since 12/01/2015
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• TALLEY, CAUSHA — adp of the snf, NOT APPLICABLE, since 10/01/2022
• TALLEY, CAUSHA — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• TALLEY, CAUSHA — managing control - governing body, NOT APPLICABLE, since 10/01/2022
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 01/18/2022
• ROADRUNNER HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• ROADRUNNER HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 10/23/2025