Cycle 1
Health 2024-10-31 · Fire 2024-10-31
3 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
St Marys, KS
Community Hospital Onaga Ltcu
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
206 Grand Avenue, St Marys, KS
(785) 437-2286
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
26
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-08-01
CMS approved date
Coverage
Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
4.18
Nurse aide staffing
Weekend hours
4.88
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
4.4%
1.1 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
5.6%
1.1 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.0%
2.8 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
23.2%
4.1 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
19.8%
19.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.9% |
18.4%
11.5 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
18.8%
5.1 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.8%
1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
3.1%
2 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
23.2%
4.9 pts better
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.6%
1.9 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-19 · Fire 2023-06-19
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-12-21 · Fire 2021-12-21
1 health deficiencies
Top issue: Infection Control (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-23
F · Potential for more than minimal harm
2023-06-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-06-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-06-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-12
F · Potential for more than minimal harm
2021-12-21
K222 · Egress Deficiencies
Fire Safety
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 2022-02-28
F · Potential for more than minimal harm
2021-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-02-28
F · Potential for more than minimal harm
2021-12-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-28
F · Potential for more than minimal harm
2021-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-28
F · Potential for more than minimal harm
2021-12-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-02-28
F · Potential for more than minimal harm
2021-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-28
F · Potential for more than minimal harm
2021-12-21
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-02-28
F · Potential for more than minimal harm
2021-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-28
E · Potential for more than minimal harm
2021-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-28
D · Potential for more than minimal harm
2021-12-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-02-28
D · Potential for more than minimal harm
2021-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-28
D · Potential for more than minimal harm
2021-12-21
K902 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2022-02-28
D · Potential for more than minimal harm
2021-12-21
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2022-02-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-31
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-31
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-11-18
D · Potential for more than minimal harm
2023-06-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-19
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-19
F758 · Pharmacy Service Deficiencies
Health
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 2023-07-05
D · Potential for more than minimal harm
2021-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-19
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Rossville Healthcare & Rehab Center
Rossville, KS
1-star overall rating with 1-star inspections with Special Focus status with $60,639 in total fines with 21 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society - Valley Vista
Wamego, KS
4-star overall rating with 3-star inspections with $26,525 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Westy Community Care Home
Westmoreland, KS
2-star overall rating with 2-star inspections with $19,406 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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