1 of 5 stars overall. ONION CREEK NURSING AND REHABILITATION CENTER has very low staffing (1 of 5 stars; 3.12 nurse hours per resident per day vs the 4.1 federal benchmark), a recent federal penalty, and $51,337 in fines over the last 24 months, while health inspections were 2 of 5 stars and quality measures were 4 of 5 stars.
Last inspection: January 28, 2026Penalties, last 24 months: $51,337recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.1151.
Staffing detail
Registered nurses
0.27
Licensed practical nurses
0.98
Nurse aides
1.87
Weekend nursing
2.74
Hours per resident per day.
Total staff turnover: 61%
Registered nurse turnover: 75%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Last yrNowTrend
Long-stay residents on antipsychotic medication
8.1%5.6%Improving
Residents with a fall causing major injury
8.4%1%Improving
Residents with pressure ulcers (bedsores)
0%1.7%Worsening
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
6%0%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
27.7%13.3%Improving
Residents whose ability to walk got worse
19.5%11.3%Improving
Long-stay residents on antianxiety or sleep medication
9.3%10.3%Worsening
Short-stay residents newly given an antipsychotic
1.8%1.3%No change
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
28.5%20.1%Improving
Residents with depressive symptoms
2.8%2.2%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Last yrNowTrend
Long-stay residents given the seasonal flu vaccine
—95%—
Long-stay residents given the pneumonia vaccine
98.9%82.7%Worsening
Short-stay residents given the seasonal flu vaccine
—59%—
Short-stay residents given the pneumonia vaccine
70.1%49.6%Worsening
What the inspectors found
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited April 2025 — limited pattern, immediate jeopardy to residents.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: K
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited February 2025 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited October 2024 — limited pattern, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: H
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited February 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The nursing home failed to ensure residents were free from significant medication errors. Cited November 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: E
Recent history
STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
PENALTY
A federal fine of $42,224 was recorded.
PENALTY
A federal fine of $9,113 was recorded.
Penalties & enforcement
On record with Medicare: 2 fines · $51,337 in total fines.
Federal fine
Apr 5, 2025
$42,224
Federal fine
Feb 19, 2025
$9,113
Operator & ownership
Ownership
For profit - Corporation
Chain
Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
Occupancy
111.1 residents on an average day (89% of 125 beds)
Resident voice
Resident council
Medicare history
Certified for 15 years
The most recent standard health inspection was more than two years ago.
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.