Onaga Operator, LLC
500 Western Street, Onaga, KS 66521 · Pottawatomie County · 45 certified beds · avg 28 residents/day · certified since Apr 1, 1992
Part of chain: MISSION HEALTH COMMUNITIES (30 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 28, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 11, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Mar 13, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 13, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, facility-wide · Dec 7, 2023 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Nov 16, 2023 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Dec 7, 2023 · F-0604 · triggered by a complaint
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 16, 2023 (Past Non-Compliance)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 30, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 30, 2026 | C · Minimal risk, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Apr 30, 2026 | C · Minimal risk, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Jul 28, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 2, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Oct 2, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 2, 2024 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Mar 13, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 7, 2023 | ▲ L · Immediate jeopardy, facility-wide | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 7, 2023 | ▲ J · Immediate jeopardy, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Apr 5, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Apr 5, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Apr 5, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 5, 2023 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 2 | L ▲ |
| 2024 | 8 | 1 | J ▲ |
| 2025 | 1 | 1 | J ▲ |
| 2026 | 3 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $42,578.
| Date | Type | Amount / length |
|---|---|---|
| Jul 28, 2025 | Fine | $16,149 |
| Mar 13, 2024 | Fine | $14,518 |
| Dec 7, 2023 | Fine | $11,911 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Kansas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.28 | 4.58 | 3.95 | bottom 43% in Kansas; top 30% in the U.S. |
| Registered Nurse hours | 0.52 | 0.81 | 0.69 | bottom 20% in Kansas; bottom 41% in the U.S. |
| Weekend total nurse staffing | 3.65 | 4.05 | 3.50 | bottom 38% in Kansas; top 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.49 | 0.48 | top 47% in Kansas; top 38% in the U.S. |
| Total nursing staff turnover (%) | 33.3 | 48.1 | 45.8 | top 15% in Kansas; top 20% in the U.S. |
| RN turnover (%) | 0.0 | 42.0 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.90, RN 0.47, weekend 3.33. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 3/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Barres, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/26/2015 |
| Crino, Bryan | Individual | 5% or Greater Indirect Ownership Interest | — | 02/26/2015 |
| Feuer, Scott | Individual | 5% or Greater Indirect Ownership Interest | — | 02/26/2015 |
| Kansas Operator LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/25/2015 |
| Lindeman, Stuart | Individual | 5% or Greater Indirect Ownership Interest | — | 02/26/2015 |
| Passero, Joseph | Individual | 5% or Greater Indirect Ownership Interest | — | 02/26/2015 |
| T and C Capital Assets, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/26/2015 |
| Windward Health Partners LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/26/2015 |
| Barnes, Michelle | Individual | Corporate Director | NOT APPLICABLE | 12/01/2018 |
| Lindeman, Stuart | Individual | Corporate Officer | NOT APPLICABLE | 02/26/2015 |
| Lindeman, Stuart | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/26/2015 |
| Mission Health Communities, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/26/2015 |
| Yoakum, Jamie | Individual | Corporate Officer | NOT APPLICABLE | 03/20/2024 |
| Yoakum, Jamie | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/20/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
- "If you ever planned to discharge or transfer my family member, how much written notice would we receive and how could we appeal?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Westy Community Care Home | 15.3 mi | Westmoreland, KS | ★☆☆☆☆ | 2/5 | |
| Eastridge | 16.3 mi | Centralia, KS | ★★☆☆☆ | 1/5 | |
| Frankfort Community Care Home | 19.4 mi | Frankfort, KS | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 175220.