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| Deficiency Category | Inspection Date: 2/28/25 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 3/11/24 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 3/31/23 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 2/28/25Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 2/28/25Read the full report (PDF) 11/26/24Read the full report (PDF) 10/10/24Read the full report (PDF) 8/13/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Illinois: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 10/10/24 | 11/19/24 | 2 - Minimal harm or potential for actual harm | Many |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/10/24 | 11/19/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 10/10/24 | 11/19/24 | 3 - Actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/10/24 | 11/19/24 | 4 - Immediate jeopardy to resident health or safety | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/28/25 | 3/21/25 | 3 - Actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 2/28/25 | 3/21/25 | 3 - Actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 8/13/24 | 8/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/10/24 | 11/22/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 11/26/24 | 11/27/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Few |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Post nurse staffing information every day. | 2/28/25 | 3/21/25 | 1 - Potential for minimal harm | Many |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 10/10/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Many |
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Some |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Few |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 3/11/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 10/19/23Read the full report (PDF) 9/27/23Read the full report (PDF) 4/25/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Illinois: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 6/6/23 | 6/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/25/23 | 5/10/23 | 3 - Actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 6/6/23 | 6/16/23 | 3 - Actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate foot care. | 3/11/24 | 3/29/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/11/24 | 3/29/24 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 3/11/24 | 3/29/24 | 3 - Actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/19/23 | 11/4/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 6/6/23 | 6/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/25/23 | 5/10/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 3/11/24 | 3/29/24 | 4 - Immediate jeopardy to resident health or safety | Many |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Many |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 6/6/23 | 6/16/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 10/19/23 | 11/4/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Resident Rights Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Many |
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. | 9/27/23 | 10/11/23 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have a plan that describes the process for conducting QAPI and QAA activities. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Many |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 3/11/24 | 3/29/24 | 2 - Minimal harm or potential for actual harm | Many |
| Date of last standard health inspection: | 3/31/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 3/31/23Read the full report (PDF) 10/18/22Read the full report (PDF) 9/29/22Read the full report (PDF) 6/13/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Illinois: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Respond appropriately to all alleged violations. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/18/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 9/29/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Some |
Respond appropriately to all alleged violations. | 9/29/22 | 10/18/22 | 4 - Immediate jeopardy to resident health or safety | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 9/29/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 6/13/22 | 7/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | 10/18/22 | 11/2/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 3/31/23 | 6/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 3/31/23 | 6/1/23 | 3 - Actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 9/29/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 3/31/23 | 6/1/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 10/18/22 | 11/2/22 | 2 - Minimal harm or potential for actual harm | Some |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 10/18/22 | 11/2/22 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 10/10/24 | 11/19/24 | 2 - Minimal harm or potential for actual harm | Many |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/10/24 | 11/19/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 10/10/24 | 11/19/24 | 3 - Actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/10/24 | 11/19/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 8/13/24 | 8/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/10/24 | 11/22/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 11/26/24 | 11/27/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 10/10/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Many |
Reasonably accommodate the needs and preferences of each resident. | 2/28/25 | 3/21/25 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 6/6/23 | 6/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/25/23 | 5/10/23 | 3 - Actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 6/6/23 | 6/16/23 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/19/23 | 11/4/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 6/6/23 | 6/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/25/23 | 5/10/23 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 6/6/23 | 6/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 10/19/23 | 11/4/23 | 2 - Minimal harm or potential for actual harm | Many |
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. | 9/27/23 | 10/11/23 | 2 - Minimal harm or potential for actual harm | Many |
Respond appropriately to all alleged violations. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/18/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 9/29/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Some |
Respond appropriately to all alleged violations. | 9/29/22 | 10/18/22 | 4 - Immediate jeopardy to resident health or safety | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 9/29/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 6/13/22 | 7/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | 10/18/22 | 11/2/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 3/31/23 | 6/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Many |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 3/31/23 | 6/1/23 | 3 - Actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 3/31/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 9/29/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 3/31/23 | 6/1/23 | 2 - Minimal harm or potential for actual harm | Many |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 10/18/22 | 11/2/22 | 2 - Minimal harm or potential for actual harm | Some |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 10/18/22 | 11/2/22 | 2 - Minimal harm or potential for actual harm | Many |
| This nursing home has not had any infection control inspections in the past 3 years. |