Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vancrest Of Ada during CMS and state inspections, most recent first.
A resident with significant medical conditions was left on a bedpan for an extended period, resulting in a deep tissue injury to the buttocks. Staff were unable to determine who placed the resident on the bedpan or for how long, and upon discovery of the injury, failed to properly assess, document, and notify appropriate clinical staff as required by facility policy.
A resident with multiple chronic conditions developed a new skin impairment that was documented by staff, but neither the provider nor the resident's representative were notified as required by facility policy. Interviews confirmed that both the wound NP and another NP were not informed of the change, and the DON verified the lack of notification. Facility policy mandates prompt notification of such changes, which did not occur in this case.
The facility failed to maintain a clean and sanitary kitchen environment, affecting all 37 residents. Observations revealed grease buildup around the deep fryer, dried food on oven handles, and improper storage of the ice scoop. These findings were confirmed by a staff member, contradicting the facility's sanitization policy.
The facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) to two residents, resulting in a deficiency. One resident, with conditions including hemiplegia and diabetes, remained in the facility after Medicare Part A services ended without receiving a SNFABN. Another resident, with atrial fibrillation and muscle weakness, also stayed beyond the end of Medicare Part A services without a SNFABN. The administrator confirmed the oversight for both residents.
A facility failed to implement a baseline care plan within 48 hours of admission for a resident with chronic systolic heart failure. The care plan did not include the treatment of Tubigrips and ace wraps, despite a physician's order. Observations revealed the resident without ace wraps, and staff confirmed the omission. The resident was informed by staff that ace wraps were no longer needed, contrary to the physician's order.
A facility failed to implement a comprehensive care plan for a resident with a significant contracture in the right hand. Despite previous orders for a palm protector, the resident reported not wearing any splints or braces recently. Observations and interviews confirmed the absence of a care plan addressing contracture management, highlighting a deficiency in the resident's care planning.
A facility failed to provide prescribed treatments for two residents. One resident with a contracture did not receive the ordered palm protector, and the care plan lacked details on contracture management. Another resident with chronic systolic heart failure did not have ace wraps applied over Tubigrips as ordered, with staff indicating they were no longer needed. These deficiencies highlight a lack of adherence to treatment plans.
A resident with severe dementia was injured after spilling hot chocolate on herself due to the facility's failure to provide a Kennedy cup as ordered. The resident, who requires supervision and cueing for eating, was not assisted or supervised at the time of the incident. Staff interviews confirmed the oversight, with the CNA unaware of the requirement and the DON acknowledging the order for the Kennedy cup.
The facility did not follow physician orders for changing oxygen tubing for three residents, including one with asthma and another with COPD. The tubing was found to be outdated by several weeks, contrary to the weekly change requirement. This was confirmed by CNAs and contradicted the facility's policy.
A facility failed to follow pharmacy recommendations for a resident, leading to an unobserved medication error. The resident, with multiple diagnoses, had orders for medications that should not be crushed. Despite a pharmacy recommendation to consider holding or discontinuing these medications if crushing was necessary, an LPN crushed them due to the resident's difficulty swallowing whole pills, unaware of the recommendation.
A facility failed to ensure a resident was free from unnecessary antibiotics, as the resident was placed on long-term antibiotic prophylaxis without a current UTI diagnosis or stop date, influenced by the resident's daughter. The Infection Disease Nurse did not complete a Time Out Sheet, and the facility's antibiotic stewardship policy was not followed, as the prescribed cephalexin is not indicated for prolonged use.
A resident with type two diabetes experienced a significant medication error when an LPN failed to prime a Novolog FlexPen before administering insulin. The LPN, unaware of the need to prime the pen, administered 4 units of insulin without following the manufacturer's instructions, potentially affecting the resident's diabetes management.
The facility did not follow the prescribed menu for residents on pureed diets, affecting three residents. A staff member served meals without a spreadsheet for correct portion sizes, using a blue-handled scoop instead of the required grey-handled scoop. Additionally, no bread was served to the residents, as the facility does not provide bread for puree diets. The menu included Italian chicken breast, AuGratin potatoes, cauliflower, dinner roll, and apple cake, but the portion size for the dinner roll was not specified.
The facility failed to follow infection control protocols during medication administration for two residents. An LPN did not wear a gown when administering IV medication to a resident on contact isolation for MRSA, and another LPN used the same glucometer for multiple residents without proper disinfection. These actions were against the facility's policies, risking cross-contamination.
A resident without a chronic UTI diagnosis was prescribed multiple antibiotics over a short period, including Cipro, Microbid, and Amoxicillin, without clear UTI indications. The resident's daughter requested antibiotic prophylaxis, leading to a Cephalexin prescription without a stop date or doctor discussion. The facility's antibiotic stewardship policy was not followed, as confirmed by the Infection Disease Nurse's failure to complete a Time Out Sheet.
The facility did not schedule a Registered Nurse (RN) for at least eight hours on a specific day, as required by their policy. A review of schedules and timecards confirmed no RN coverage on that day, which was verified by the Administrator. This oversight had the potential to affect all 54 residents in the facility.
Failure to Prevent and Assess Pressure Ulcer Following Prolonged Bedpan Use
Penalty
Summary
A resident with multiple comorbidities, including atrial fibrillation, diabetes, congestive heart failure, chronic kidney disease, liver cirrhosis, peripheral vascular disease, bilateral below-the-knee amputations, and altered mental status, was admitted to the facility and required moderate staff assistance with toileting. The resident preferred the use of a bedpan and was cognitively intact prior to the incident. On the day in question, the resident experienced increased confusion, lethargy, and other symptoms suggestive of a urinary tract infection, for which treatment was initiated. During this period of acute illness, the resident was placed on a bedpan during the night shift and was not removed for an extended period of time, with documentation and interviews indicating the resident remained on the bedpan for at least 4.5 hours. Staff were unable to determine exactly which staff member placed the resident on the bedpan or the precise duration. Upon removal of the bedpan by day shift nurses, a deep tissue injury (DTI) in the shape of the bedpan was discovered on the resident’s buttocks, with subsequent hospital records confirming the presence of a DTI and associated skin breakdown. The facility’s investigation could not substantiate neglect but acknowledged the resident was on the bedpan longer than appropriate. Following the discovery of the DTI, facility staff failed to thoroughly assess and document the wound as required by facility policy. There was no immediate measurement or detailed documentation of the wound characteristics, and key clinical staff, including the nurse practitioner and DON, were not notified of the new skin impairment in a timely manner. The facility’s established procedures for new skin impairments, including incident reporting, wound measurement, and notification, were not followed when the injury was identified.
Failure to Notify Provider and Representative of New Skin Impairment
Penalty
Summary
The facility failed to notify the provider and resident representative of a new skin impairment for a resident with multiple complex medical conditions, including atrial fibrillation, diabetes mellitus type II, congestive heart failure, chronic kidney disease stage three, liver cirrhosis, peripheral vascular disease, bilateral below the knee amputation, and altered mental status. The resident was admitted on 01/08/25 and discharged on 10/31/25. A quarterly Minimum Data Set assessment indicated the resident was cognitively intact and had no unhealed pressure ulcers at that time. On 10/24/25, a weekly wound and skin assessment documented a dark blanchable redness to the resident's bilateral buttocks, but no measurements or further wound characteristics were recorded. There were no new physician orders related to this skin impairment, and nursing progress notes did not show evidence that the nurse practitioner, wound nurse practitioner, or responsible party were notified of the new condition. Interviews with the wound NP and another NP confirmed they were not informed of the new skin impairment, despite one of them being present in the facility when the issue was identified. The Director of Nursing also verified that there was no evidence of notification to the NP or resident representative regarding the new skin impairment. Review of the facility's policy on changes in a resident's condition or status indicated that prompt notification of the resident, attending physician, and resident representative is required for changes in medical or mental condition, which was not followed in this instance.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect all 37 residents residing in the facility. During an observation, it was noted that the kitchen floor surrounding the deep fryer had a thick amount of grease, and both sides of the deep fryer were similarly affected. The oven handles were covered with a large amount of dried food substances, and the shelf above the range, although covered in aluminum foil, was black with food and grease. Additionally, the two shelves above the steam table had a moderate film of grease build-up, and the top of the convection oven had a thick film of black grease. Furthermore, the ice scoop was improperly stored inside the machine on top of the ice. These findings were verified by a staff member during an interview. A review of the facility's sanitization policy revealed that all kitchens and kitchen areas are required to be kept clean and free from debris.
Failure to Issue SNFABNs to Residents
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) to two residents, resulting in a deficiency. Resident #24, who was admitted with diagnoses including hemiplegia, type two diabetes mellitus, hypertension, and major depressive disorder, received a Notice of Medicare Non-Coverage (NOMNC) indicating that Medicare Part A services would end on 10/11/24. However, there was no documentation of a SNFABN being issued to Resident #24, who remained in the facility after the discontinuation of Medicare Part A services. Similarly, Resident #104, admitted with diagnoses of atrial fibrillation, type two diabetes mellitus, and muscle weakness, received a NOMNC stating that Medicare Part A services would end on 12/20/24. Despite this, there was no documentation of a SNFABN being issued, and Resident #104 remained in the facility until her discharge on 01/07/25. The facility's administrator confirmed that both residents were not issued SNFABNs and remained in the facility after Medicare Part A services were discontinued without exhausting their benefits.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #259, who was admitted with a diagnosis of chronic systolic heart failure. The resident was cognitively intact, as noted in the 5-day Minimum Data Set (MDS) assessment. The care plan initiated on January 13, 2025, did not include the treatment of Tubigrips (compression stockings) and ace wraps, despite a physician's order dated January 31, 2025, to apply Tubigrips and wrap with ace wraps every morning and remove them in the evening. Observations on February 3 and 4, 2025, revealed the resident sitting in a recliner with Tubigrips in place but without ace wraps, which were found on the counter in the resident's bathroom. The resident stated that staff informed him he no longer needed the ace wraps. An interview with LPN #173 confirmed the absence of ace wraps despite the existing order, and the Assistant Director of Nursing acknowledged that the care plan did not address the required treatment.
Failure to Implement Comprehensive Care Plan for Contracture Management
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with significant medical needs, specifically regarding contracture management. The resident, who was admitted with conditions including hemiplegia/hemiparesis following a cerebral infarction, rheumatoid arthritis, and muscle weakness, did not have a care plan addressing the contracture of the right hand. Despite previous physician orders for the use of a palm protector and orthotic application, these were not included in the current care plan, and the resident reported not wearing any splints or braces recently. Observations and interviews revealed that the resident had a significant contracture in the right hand, and staff were inconsistent in applying the palm protector, as noted in the occupational therapy discharge note. The physical therapist confirmed the presence of the contracture and was unsure of the last occupational therapy session. The MDS coordinator verified the absence of a care plan for contractures or range of motion exercises, confirming the deficiency in the resident's care planning.
Failure to Provide Prescribed Treatments for Residents
Penalty
Summary
The facility failed to provide appropriate treatment for a resident with a contracture. The resident, who had a history of hemiplegia/hemiparesis following a cerebral infarction, rheumatoid arthritis, and other conditions, was observed to have a significant contracture in the right hand. Despite previous orders for the use of a palm protector to manage the contracture, there were no current physician orders for splinting or bracing, and the care plan did not address the contracture. Interviews with staff revealed inconsistencies in the application of the palm protector, and the resident confirmed that they had not been wearing any splints or braces recently. Another resident, diagnosed with chronic systolic heart failure, did not receive treatment as per physician orders. The resident was observed without ace wraps, which were supposed to be applied over Tubigrips daily for edema management. The resident reported being informed by staff that ace wraps were no longer needed, and an LPN confirmed the absence of ace wraps despite the existing order. These deficiencies indicate a failure to adhere to prescribed treatment plans for both residents.
Failure to Implement Safety Intervention for Resident
Penalty
Summary
The facility failed to ensure that a safety intervention was in place for a resident, leading to an accident. Resident #21, who has severe cognitive impairment due to severe dementia, was supposed to use a Kennedy cup for hot liquids as per her care plan and physician orders. However, on January 17, 2025, while a CNA was placing a shirt protector, Resident #21 spilled hot chocolate on her upper thighs, resulting in redness and blisters. This incident occurred because the ordered Kennedy cup was not used, and the CNA was unaware of the requirement. Further observation on February 2, 2025, revealed that Resident #21 was again provided with a regular cup of hot chocolate without a lid, instead of the prescribed Kennedy cup. No staff were assisting or supervising her at the time. Interviews with the CNA and the DON confirmed the oversight, with the CNA admitting she was unaware of the Kennedy cup requirement, and the DON acknowledging the existing order for its use. This lack of adherence to the care plan and physician orders resulted in the resident's injury.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely changing of oxygen tubing for three residents. Resident #7, diagnosed with asthma, had oxygen tubing that was not changed weekly as ordered, with the tubing dated over a month old. Resident #22, with a history of pulmonary embolism, dementia, and heart disease, had tubing that was supposed to be changed every Thursday, but was found to be dated from several weeks prior. Resident #23, suffering from chronic obstructive pulmonary disease, also had tubing that was not changed weekly as required, with the tubing dated from the previous month. These observations were confirmed through interviews with CNAs, and the facility's policy indicated that oxygen supplies should be changed weekly during the night shift.
Failure to Follow Pharmacy Recommendations Leads to Medication Error
Penalty
Summary
The facility failed to adhere to pharmacy recommendations for a resident, resulting in an unobserved medication error. Resident #25, who was admitted with diagnoses including anemia, gastroesophageal reflux disease, migraines, and angina pectoris, had physician orders for several medications: Topamax, Protonix, Isosorbide mononitrate, and ferrous sulfate. A pharmacy recommendation dated 08/02/24 advised considering holding or discontinuing these medications if crushing became necessary long-term, which was agreed upon and signed by the physician. However, during an interview, LPN #167 revealed that she crushed all of Resident #25's medications because the resident would spit out whole medications, and she was unaware that these medications should not be crushed. A review of Medscape confirmed that these medications should be swallowed whole and not split, crushed, or chewed.
Failure to Ensure Resident Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications, specifically regarding the use of a long-term antibiotic without an adequate indication. The resident, who was admitted with diagnoses including dementia with behavioral symptoms, major depressive disorder, and anxiety, did not have a diagnosis of chronic urinary tract infections (UTI). Despite this, the resident was prescribed various antibiotics over a period of time for UTIs, and eventually placed on a daily antibiotic prophylaxis without a current UTI diagnosis or a stop date for the medication. The decision to place the resident on prophylactic antibiotics was influenced by the resident's daughter, who requested it due to the resident's history of diarrhea when on antibiotics. The facility's Infection Disease Nurse did not complete a Time Out Sheet, which is a form used to address overuse of medication, because the family requested the antibiotic. The nurse acknowledged that cephalexin, the antibiotic prescribed, is not indicated for prolonged use. The facility's policy on Antibiotic Stewardship requires that antibiotic orders include specific elements such as the drug name, dose, frequency, duration of treatment, and indication of use, which were not adhered to in this case. Additionally, information from Medscape indicated that prolonged use of cephalexin could lead to fungal or bacterial superinfection, highlighting the importance of adhering to proper antibiotic stewardship practices.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure proper insulin administration procedures were followed, resulting in a significant medication error for a resident. The resident, who was cognitively intact and had a medical history including type two diabetes, was prescribed insulin injections as part of their treatment plan. During an observation, an LPN administered insulin using a Novolog FlexPen without priming it as per the manufacturer's instructions. The LPN checked the resident's blood sugar, which was 208, and determined that 4 units of insulin were required according to the sliding scale. However, the LPN did not prime the insulin pen with two units before administering the dose, which is a necessary step to ensure accurate dosing and prevent air bubbles from affecting the insulin delivery. The LPN admitted during an interview that she was unaware of the need to prime the insulin pen before each use. The package insert for the Novolog FlexPen clearly states the requirement to prime the pen with two units of insulin before each injection to ensure proper function and dosage accuracy. This oversight in following the manufacturer's guidelines led to a significant medication error, affecting the resident's insulin administration and potentially impacting their diabetes management.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets, affecting three residents. During an observation, a staff member was seen serving meals without a spreadsheet to indicate correct portion sizes. The staff member used a blue-handled scoop, which portions out one quarter cup, instead of the required grey-handled scoop that portions out one half cup, as per the facility's spreadsheet. Additionally, the staff member did not serve any bread to the residents, stating that the facility does not serve bread to puree diets because it clumps. The menu for the day included Italian chicken breast, AuGratin potatoes, cauliflower, dinner roll, and apple cake, but the portion size for the dinner roll was not specified for the pureed diet.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, affecting two residents. For Resident #1, who had a diagnosis of MRSA and was on contact isolation, the LPN did not wear a gown before entering the room to administer IV medication through a PICC line. This was contrary to the facility's policy, which required wearing a disposable gown upon entering a contact precaution room to prevent the transmission of microorganisms. For Resident #15, the LPN used the same glucometer for multiple residents without proper disinfection between uses. After checking the resident's blood sugar, the LPN cleaned the glucometer with an alcohol pad, which was not in line with the facility's policy that required reusable equipment to be cleaned and disinfected or sterilized between residents according to manufacturers' instructions. This practice could potentially lead to cross-contamination among residents.
Failure in Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to conduct an ongoing review for antibiotic stewardship, affecting one resident out of five reviewed for this issue. The resident, who was admitted with diagnoses including dementia with behavioral symptoms, major depressive disorder, malnutrition, cognitive communication deficit, and anxiety, did not have a diagnosis of chronic urinary tract infections (UTI). Despite this, the resident was prescribed multiple antibiotics over a short period for UTIs, including Cipro, Microbid, and Amoxicillin, without a clear indication of a UTI diagnosis. Additionally, the resident's daughter requested antibiotic prophylaxis due to past experiences of diarrhea when on antibiotics, leading to the prescription of Cephalexin for UTI prevention without a stop date or a discussion with the doctor about discontinuing the antibiotic. The Infection Disease Nurse did not complete a Time Out Sheet, which is a form used to address overuse of medication, because the family requested the antibiotic. The facility's policy on antibiotic stewardship requires prescribers to include specific elements in antibiotic orders, such as drug name, dose, frequency, duration, route of administration, and indications of use. However, this policy was not followed in the case of the resident, as the Cephalexin prescription lacked a stop date and was not indicated for prolonged use. The review of Medscape information confirmed that prolonged use of Cephalexin is associated with risks of fungal or bacterial superinfection.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight hours every day, as required by their policy. This deficiency was identified during a review of nursing schedules and timecards, which revealed that no RN was scheduled or worked on September 1, 2024. An interview with the Administrator on September 4, 2024, confirmed the lack of RN coverage on that date. The facility's policy, dated August 2022, mandates that an RN provides services for at least eight hours every 24 hours, seven days a week, with the possibility of more hours depending on resident acuity needs. This oversight had the potential to affect all 54 residents residing in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Ridge Of Mennonite Home Communities Of Ohio | 8.4 mi | ★★★★★ | 0 | 0 |
| Mennonite Memorial Home | 9.1 mi | ★★★★★ | 0 | 0 |
| Lost Creek Rehabilitation And Nursing Center | 10.9 mi | ★★★★★ | 0 | 0 |
| Serenity Spring Senior Living At Arlington | 12 mi | ★★★★★ | 0 | 0 |
| Carecore At Lima | 13.7 mi | ★★★★★ | 2 | 0 |
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