Above 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 Ada Care Center during CMS and state inspections, most recent first.
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.
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 | ★★★★★ | 7 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.