Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ada Care Center during CMS and state inspections, most recent first.
Food items were not properly date-marked and expired food remained in a refrigerator. Five cereal containers on the serving line lacked open and expiration dates, and four containers of low-fat cottage cheese were found past their expiration dates. The DS confirmed the labeling and expired-food issues, and the Administrator stated food should be used before expiration or discarded when expired.
Infection control failures occurred during wound care, direct resident care, meal service, and laundry handling. An LVN did not perform hand hygiene between dirty and clean steps while treating a resident with multiple leg and foot ulcers, two CNAs did not use required EBP PPE and skipped hand hygiene between caring for two residents, and staff passed trays and drinks on East Hall without cleaning their hands between residents. The laundry area was also observed with excessive dust and lint, uncovered dirty laundry containers, and poor separation of clean and dirty laundry.
Failure to Initiate Baseline Care Plans Within 48 Hours: The facility did not develop baseline care plans within 48 hours for four residents. Records showed no baseline care plans for residents with conditions including COPD, schizophrenia, diabetes with neuropathy, MS, CHF, ESRD, a fibula fracture, acute respiratory failure, bipolar disorder, autistic disorder, and ileus. The MDS/LVN stated the facility did not have separate baseline care plans and instead opened comprehensive care plans on admission and updated them as needed; the DON was unsure of the baseline care plan timeframe.
Inaccurate Smoking Status on MDS: The facility failed to ensure a resident’s MDS accurately reflected smoking status. The resident had COPD, was documented on admission as smoking and using tobacco products, and was later observed smoking during a scheduled smoking time. The resident stated staff were aware of the smoking habits, and the ADON/MDS/LVN confirmed she knew the resident smoked but did not code it on the MDS.
A resident with OSA had a CPAP order and was observed using the CPAP, but the care plan did not include CPAP-related interventions or details. Two cognitively intact residents were current tobacco users and were observed smoking or keeping smoking materials in their rooms, yet their care plans did not include smoking-related goals or interventions. Staff interviews confirmed awareness of the CPAP use and smoking status, but the care plans did not reflect these needs.
Inaccurate Smoking Safety Assessment: A resident with COPD, schizophrenia, depression, anxiety, cataracts, glaucoma, and convulsions was documented as a current tobacco user on the MDS, but the admission smoking assessment incorrectly stated the resident did not smoke. The resident reported attending smoke breaks since admission, kept cigarettes and a lighter in the room, and was observed smoking in the designated area with other residents and a CNA. Staff interviews showed the smoking assessment and related admission documentation were not accurately completed.
A resident with obstructive sleep apnea had a CPAP order to use it at bedtime and remove it each morning, but the medical record did not include the ordered CPAP settings. Staff observed the CPAP mask and machine at the bedside, and the resident stated they managed the CPAP themselves. An LVN confirmed the chart lacked a physician order for CPAP settings, and the care plan did not address CPAP use.
The facility failed to ensure smoking safety for two residents. One resident, with impaired mobility, smoked outside the designated area without a care plan addressing smoking safety. Another resident, with severely impaired cognition, was observed smoking without a required smoking apron, despite staff assistance. The DON acknowledged ongoing issues with residents smoking in non-designated areas.
The facility failed to ensure food was completely covered during service, violating their food handling policy. Dessert was served on a saucer with an inadequate plastic lid due to a shortage of bowls and improper plastic wrap size. The dietary manager confirmed that new dessert dishes were on order, but not yet received, affecting 57 residents.
The facility failed to adhere to infection control protocols, including improper disposal of biohazard materials and PPE. An LPN disposed of a lancet and blood-contaminated strip in a resident's room trash instead of a sharps container. Additionally, enhanced barrier precautions were not followed for two residents, with used PPE and supplies discarded in hallway trash cans instead of resident rooms. The DON confirmed these actions were against facility policy.
The facility failed to revise care plans for two residents regarding smoking safety. One resident, with conditions including diabetes and anxiety, was observed smoking in a non-designated area without safety interventions in their care plan. Another resident, with a cerebrovascular accident, required a smoking apron but was observed smoking without one, and their care plan lacked this intervention. Staff were unaware of the need for smoking aprons, highlighting deficiencies in care plan updates and adherence to smoking policies.
A facility failed to document the rationale for extending the PRN use of Ativan for a resident with anxiety beyond the 14-day limit, as required by their policy. Despite a pharmacy report suggesting compliance with CMS requirements, the physician added the PRN order to the routine dose without proper documentation. Interviews confirmed the oversight in evaluating the PRN order every two weeks.
Food Not Properly Date-Marked and Expired Food Left in Refrigerator
Penalty
Summary
The facility failed to ensure food was labeled with the open date and expiration date for five large plastic containers of cereal on the serving line. During an initial kitchen observation, the containers of raisin bran, fruit loops, rice krispies, corn flakes, and bran were found with closed lids and were being used to pour individual servings, but none of the containers were dated to show when the cereal had been opened or when it expired. The Dietary Supervisor stated the original cereal packages had been opened and the contents placed into the plastic containers for easier service, and confirmed the containers lacked the required open and expiration dates. The facility also failed to remove expired food from Refrigerator #1. Four 5-pound containers of low-fat cottage cheese were observed in the refrigerator after their expiration dates, including one container expired on 01/06/2026 and three containers expired on 05/13/2026. The Dietary Supervisor confirmed the cottage cheese had expired and should have been used before the expiration date or discarded on the expiration date, and stated the containers should have been thrown away. The Administrator stated she expected kitchen staff to use food before it expired or throw it away when it expired.
Infection Control Failures During Wound Care, Resident Care, Meal Service, and Laundry Handling
Penalty
Summary
The facility failed to ensure hand hygiene was performed between handling soiled and clean items during wound care for two residents. One resident had a history that included basal cell carcinoma, restless leg syndrome, and multiple venous and/or arterial ulcers, and required scheduled and PRN wound care to both lower legs and feet. During observed wound care, an LVN gathered supplies, donned gown and gloves without first performing hand hygiene, cleaned the resident’s bilateral legs, removed gloves, donned clean gloves without hand hygiene, applied betadine, Medihoney, and Silvadene, and again changed gloves without performing hand hygiene. The LVN stated she changed gloves between tasks but was not aware hand hygiene was needed between glove changes. The facility also failed to ensure hand hygiene was performed between direct care tasks for two residents and that staff used the required PPE for residents on enhanced barrier precautions. One resident had an indwelling urinary catheter and care plan directions to use EBP for high-contact care. Another resident had diagnoses including severe sepsis without septic shock and cellulitis of the left lower limb, scored 15 on BIMS, and required partial/moderate assistance with bed mobility. During observation, two CNAs provided a linen change for the first resident without donning PPE other than gloves, then left the room and entered the second resident’s room with a bedpan without performing hand hygiene. After caring for the second resident, they exited, handled the bedpan and soiled linen area, and again did not perform hand hygiene. One CNA acknowledged she did not use proper PPE and the other stated she was not really sure of the difference between EBP and transmission-based precautions. Hand hygiene was also not performed between residents during food and beverage service on East Hall. CNAs and a CMA entered and exited multiple resident rooms while delivering meal trays, pouring liquids, and handing out milk and ice without cleaning their hands between residents. One CNA touched a wheelchair in the corridor and continued serving ice without hand hygiene, then pushed a meal cart and entered another resident’s room without washing her hands. The laundry area was also observed to be dirty and poorly maintained, with excessive dust and dryer lint, dirty laundry containers not covered, and clean and dirty laundry not separated. The laundry room floor had cracked and exposed cement, and staff interviews indicated the area was not being monitored for infection control and that training for the laundry supervisor was informal and undocumented.
Failure to Initiate Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to initiate baseline care plans within 48 hours of admission for 4 of 7 residents reviewed. The facility policy titled, "Baseline Care Plan," revised on 06/30/2025, stated that a baseline care plan would be developed and implemented for each resident and that a supervising nurse would verify within 48 hours that the baseline care plan had been developed. However, review of the medical records for Residents #4, #25, #28, and #44 showed no baseline care plan documented within that timeframe. Resident #25 was admitted with diagnoses including COPD, schizophrenia, major depressive disorder, anxiety disorder, nuclear cataract, bilateral primary open-angle glaucoma, and convulsions. The resident had a BIMS score of 15, indicating intact cognition. The record showed no baseline care plan, and the comprehensive care plan was started 7 days after admission. Resident #28 was admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, parkinsonism, multiple sclerosis, paroxysmal atrial fibrillation, acute diastolic CHF, COPD, and end stage renal disease. This resident also had a BIMS score of 15, no baseline care plan was found, and the comprehensive care plan was started 6 days after admission. Resident #4 was admitted with a nondisplaced comminuted fracture of the right fibula and had a BIMS score of 15. No baseline care plan was documented, and the comprehensive care plan was started 7 days after admission. Resident #44 was admitted with acute respiratory failure, bipolar disorder, autistic disorder, and ileus. No baseline care plan was found, the resident had no BIMS completed, and the comprehensive care plan was started 3 days after admission. During interviews, the MDS/LVN stated the facility did not have separate baseline care plans and that comprehensive care plans were initiated on admission and updated as needed. The DON stated she expected care plans to be completed in a timely manner but was unsure of the baseline care plan timeframe.
Inaccurate Smoking Status on MDS
Penalty
Summary
The facility failed to ensure that Resident #28’s most recent assessment accurately reflected the resident’s smoking status. The CMS Resident Assessment Instrument 3.0 User’s Manual for J1300 required the assessor to determine whether the resident used tobacco during the 7-day look-back period and to code tobacco use based on the resident’s report or other available sources. Resident #28 was admitted on 04/29/2026 with a history of COPD, and an admission assessment completed by LVN #3 documented that the resident smoked, used electronic cigarettes, or used tobacco products at the time of assessment. However, the admission MDS with an ARD of 05/12/2026 coded J1300 to indicate that the resident did not use tobacco. The resident had intact cognition with a BIMS score of 15. During observation on 06/01/2026, Resident #28 was seen outside smoking during a scheduled smoking time, and during interview the resident stated they usually kept smoking material on their person or in the nightstand drawer and that staff were aware of the smoking habits. LVN #3 stated the resident told him they were an unsupervised smoker at admission, and the DON and ADON/MDS/LVN acknowledged they were aware the resident smoked, with the ADON/MDS/LVN confirming she did not reflect that on the MDS.
Care Plans Did Not Reflect CPAP Use or Smoking Status
Penalty
Summary
The facility failed to ensure that Resident #10’s comprehensive person-centered care plan accurately reflected the resident’s respiratory status and use of CPAP therapy. Resident #10 was admitted with a history of obstructive sleep apnea, had a BIMS score of 15, and had an active order to ensure a CPAP was on at bedtime and removed every morning. The order summary did not include specific CPAP settings, and the care plan included a focus area for altered respiratory status related to obstructive sleep apnea, but it did not include any information about the resident’s CPAP use. Observations showed the CPAP mask on top of the resident’s bed, the CPAP machine in an open dresser drawer next to the bed, and later the resident holding the mask to their face while preparing to nap. The resident stated they managed the CPAP themselves, including turning the machine on and off, and later was observed sleeping with the CPAP mask on. During interview, an LVN stated that if a resident used a CPAP, it should have been documented on the care plan. The ADON/MDS/LVN stated she was aware the resident had a CPAP machine and that a care plan should be in place for it, but there had been no MDS triggers to put it in the care plan. The facility also failed to include smoking-related care plan information for Resident #25 and Resident #28, both of whom were current tobacco users with intact cognition. Resident #25 had COPD, schizophrenia, depression, anxiety, cataracts, glaucoma, and unspecified convulsions, and Resident #28 had COPD. Both residents were observed smoking or having smoking materials available, and both stated they kept cigarettes or smoking materials on their person or in their room. Their care plans addressed ADL deficits but did not include smoking-related goals or interventions. Staff interviews confirmed awareness that both residents smoked, and the DON stated smoking should be reflected on a resident’s care plan.
Inaccurate Smoking Safety Assessment
Penalty
Summary
The facility failed to accurately complete a smoking safety assessment for Resident #25 to determine the resident’s potential hazards or risks related to smoking. The facility policy titled Resident Smoking stated that residents who smoke are to be assessed to determine whether supervision is required or whether the resident is safe to smoke at all, and that documentation supporting the decision is to be included in the medical record. Resident #25 was admitted on 04/30/2026 with diagnoses including COPD, schizophrenia, major depressive disorder, anxiety disorder, cataracts, glaucoma, and unspecified convulsions. The admission MDS showed a BIMS score of 15, indicating intact cognition, and also showed the resident required supervision or touch assistance with all ADLs and was a current tobacco user. The admission record and progress notes did not document the resident’s smoking preferences or a smoking discussion or assessment at admission. The Admission/Re-Admission/Quarterly/Significant Change Assessment dated 04/30/2026 included a Safe Smoking Evaluation that indicated Resident #25 did not currently smoke, and the assessment did not identify who completed it. This conflicted with the resident’s statements during interview that they had been attending smoke breaks since admission, kept cigarettes on them, and had received the facility rules about smoking at admission. The resident also opened a nightstand drawer and showed a carton of cigarettes, and a lighter was observed on the nightstand. During observation, Resident #25 was seen outside in the smoking area smoking with five other residents and a CNA, and the CNA stated staff were aware of which residents should be supervised and that cigarettes were kept in a locked box labeled with residents’ names. Staff interviews showed the admission smoking information was intended to be gathered during the admission process and entered into the admission packet, but LVN #2 stated the resident was a smoker and that it was an error for the assessment to reflect otherwise. The DON stated nurses were responsible for completing the smoking assessment and arranging accompaniment for smoke breaks, while the ADON/MDS/LVN stated the admission assessment was checked for completion, not for errors. The Administrator stated assessments and care plans were expected to be completed in a timely manner and that new admission charts were reviewed the following morning for additional information on residents’ needs and preferences.
Missing CPAP Settings in Physician Orders
Penalty
Summary
The facility failed to ensure physician orders for a CPAP machine included the ordered settings for Resident #10, who was admitted with a history of obstructive sleep apnea and had intact cognition with a BIMS score of 15. The resident’s care plan identified a risk for altered respiratory status related to obstructive sleep apnea, but it did not include information about CPAP use. The order summary contained an order to place the CPAP on at bedtime and remove it each morning, but it did not include specific CPAP settings. During observations, the CPAP mask was seen on top of the resident’s bed, the CPAP machine was observed in an open dresser drawer next to the bed, and the resident was later observed holding the mask to their face while preparing to nap. The resident stated they managed the CPAP themselves, including turning the machine on and off and cleaning the mask. An LVN reviewed the orders and confirmed the medical record did not contain a physician order for CPAP settings, and another LVN stated that, to his knowledge, he had not seen orders specifically for CPAP settings. The Administrator stated she expected medical staff to have all appropriate orders in place for resident care.
Failure to Ensure Smoking Safety for Residents
Penalty
Summary
The facility failed to ensure adequate safety for residents who smoke, specifically for two residents identified in the report. Resident #43, who has diagnoses including diabetes and anxiety, was assessed as able to smoke independently. However, the resident's care plan did not address smoking safety, despite a documented self-care performance deficit related to impaired mobility. Observations revealed that Resident #43 smoked outside the designated smoking area on multiple occasions, and there was no receptacle for cigarette disposal in the area where the resident was smoking. The Director of Nursing (DON) acknowledged the ongoing issue of residents smoking in non-designated areas. Resident #2, who has a cerebrovascular accident and severely impaired cognition, was assessed to require supervision and a smoking apron for safety. Despite this, observations showed that Resident #2 was not wearing a smoking apron while smoking, even though staff were present to assist with smoking materials. A Certified Nursing Assistant (CNA) was unaware of the requirement for a smoking apron, and the DON confirmed that Resident #2 should have been wearing one. These deficiencies indicate a failure to adhere to the facility's smoking policy and ensure resident safety.
Failure to Properly Cover Food During Service
Penalty
Summary
The facility failed to ensure that food was completely covered while being served, which is a violation of their Preventing Foodborne Illness-Food Handling policy. During an observation of the noon meal, it was noted that dessert was served on a saucer with a plastic lid that did not fully cover the cake. This occurred because the facility was out of bowls and the available plastic wrap was not the proper size. The dietary manager confirmed that the administrator had ordered new dessert dishes, but they had not yet arrived. As a result, 57 residents received meals from the kitchen that did not adhere to the facility's food handling standards.
Infection Control Deficiencies in PPE and Biohazard Disposal
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during blood glucose monitoring and the disposal of personal protective equipment (PPE). For Resident #105, a Licensed Practical Nurse (LPN) improperly disposed of a lancet and blood-contaminated glucometer strip by rolling them in a glove and discarding them in the trash within the resident's room, contrary to the facility's policy which mandates disposal in a sharps container. This incident was acknowledged by the LPN, the administrator, and the Assistant Director of Nursing (ADON), all of whom confirmed the correct procedure was not followed. Additionally, the facility did not adhere to enhanced barrier precautions for Residents #2 and #204. An LPN was observed exiting Resident #204's room with used catheter care supplies and a used gown, discarding them in a trash can on the treatment cart in the hallway, rather than in the resident's room as required. Similarly, for Resident #2, the LPN failed to don a gown while performing wound care, despite the presence of enhanced barrier precautions signage. The LPN admitted to not noticing the signage and routinely discarding used supplies in the hallway trash can, which was confirmed by the Director of Nursing (DON) as not following the facility's policy.
Failure to Revise Smoking Safety Care Plans
Penalty
Summary
The facility failed to revise care plans related to smoking interventions for two residents, leading to deficiencies in smoking safety. Resident #43, who had diagnoses including diabetes, anxiety, and chronic pain, was assessed as able to smoke independently. However, their care plan did not address smoking safety or interventions, despite the resident being observed smoking in a non-designated area. The resident kept their smoking materials in their room and smoked on the back porch, contrary to the facility's smoking policy. The Director of Nursing acknowledged the ongoing issue of residents smoking in non-designated areas and confirmed that care plans should include smoking safety measures. Resident #2, diagnosed with a cerebrovascular accident, required supervision and a smoking apron for safety while smoking. Despite this, their care plan did not include the necessary intervention for a smoking apron. The resident was observed smoking without a smoking apron, and a CNA was unaware of any residents requiring one. The MDS coordinator confirmed that smoking interventions should be included in the resident's care plan. These oversights indicate a failure to update and implement care plans in accordance with the facility's smoking policy and residents' assessed needs.
Failure to Document Rationale for Extended PRN Use of Ativan
Penalty
Summary
The facility failed to ensure compliance with regulatory requirements regarding the use of PRN psychotropic medications for a resident with anxiety. The resident, who had diagnoses including heart failure, hypertension, and anxiety/depression, was prescribed Ativan on a PRN basis for anxiety. According to the facility's Psychotropic Medication Use policy, PRN orders for psychotropic medications are limited to 14 days unless a clinical rationale for extending the use is documented. However, the facility did not provide a documented rationale for the continued use of Ativan beyond the 14-day limit. A pharmacy report highlighted the need for compliance with CMS requirements, suggesting that the PRN order be discontinued or changed to a routine order. Despite this, the physician disagreed with the recommendation and added the PRN order to the routine dose without providing the necessary documentation. Interviews with the ADON and DON confirmed that the PRN order was considered part of the routine order, but they acknowledged the requirement for evaluation every two weeks, which was not documented in this case.
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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) |
|---|---|---|---|---|
| Jan Frances Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Ballard Nursing Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Callaway Nursing Home | 25.7 mi | ★★★★★ | 1 | 0 |
| Heartway At Heritage Village Health And Rehab | 26 mi | ★★★★★ | 9 | 0 |
| Boyce Manor Nursing Home | 26 mi | ★★★★★ | 0 | 0 |
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