Vancrest of Ada

In the surveyor’s words

From the most serious findings on record at Vancrest of Ada, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 6, 2025

  Based on closed medical record review, review of hospital records, review of the facility submitted Self-Reported Incident (SRI), review of staff and resident statements, resident and staff interview, and review of the facility policy, the facility failed to ensure residents did not develop avoidable, facility acquired, pressure ulcers. This resulted in actual harm for Resident #50 on 10/24/25 when facility staff placed the resident on a bedpan and failed to check on her and remove her from the bedpan for an extended period of time. Consequently, Resident #50 developed a deep tissue injury (DTI - a type of pressure injury that begins in the deeper tissues and is caused by prolonged pressure) on her buttocks. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2025

  Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen environment. This had the potential to affect all 37 residents residing in the facility. The facility census was 51. Findings include: Observation on 02/03/25 beginning at 8:40 A.M. revealed the kitchen floor surrounding the deep fryer had a thick amount of grease as well as both left and right sides of the deep fryer; the handles of the oven had a large amount of dried food substances; the shelf above the range was covered in aluminum foil but black with foods and grease; the two shelves above the steam table had a moderate film of grease build-up; the top of the convection oven had a thick film of black grease; and the ice scoop was stored inside the machine on top of… […]

• No harm, potential for more than minimal, widespreadF727Sep 4, 2024

  Based on review of nursing schedules, review of timecards, staff interview, and policy review, the facility failed to ensure an Registered Nurse (RN) was scheduled for at least eight hours everyday. This had the potential to affect all 54 residents residing in the facility. Findings include: Review of the daily schedule dated 09/01/24 revealed no RN was scheduled. Review of the RN nursing timecards for 09/01/24 revealed no RN worked on 09/01/24. Interview on 09/04/24 at 1:06 P.M. with the Administrator verified the facility had no RN coverage for 09/01/24. Review of the policy titled Staffing, Sufficient and Competent Nursing dated August 2022 revealed a Registered Nurse provides services at least eight hours every 24 hours, seven days a week. […]

• No harm, potential for more than minimal, patternF636May 18, 2023

  Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) 3.0, the facility failed to complete admission Minimum Data Set (MDS) assessments within the required timeframe. This affected four (#208, #209, #212 and #55) out of the four residents reviewed for timely completion of admission MDS assessments. The facility census was 53. Findings include: 1. Review of the medical record for Resident #212 revealed an admitted [DATE] with medical diagnoses of hypotension, atrial fibrillation, status post left hip fracture, and chronic obstructive pulmonary disease. […]

• No harm, potential for more than minimal, isolatedF580Nov 6, 2025

  Based on closed medical record review, staff interview, Nurse Practitioner (NP) interview, and review of facility policy, the facility failed to notify the provider and resident representative of a new skin impairment. This affected one (#50) of one resident reviewed for notification of change. The facility census was 48. Findings include:Review of the closed medical record for Resident #50 revealed an admission date of 01/08/25 and a discharge date of 10/31/25. Diagnoses included atrial fibrillation (abnormal heart beat), diabetes mellitus type II, congestive heart failure (CHF), chronic kidney disease (CKD) stage three (CKD is measured in stages one through four, stage four requires renal dialysis), liver cirrhosis, peripheral vascular disease (PVD), bilateral (both sides) below the knee… […]