Vancrest of Ada

Inspectors wroteBased 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. Additionally, upon discovery of the DTI, the facility failed to thoroughly assess and document the DTI. This affected one (#50) of three residents reviewed for pressure ulcers. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, review of Medicare beneficiary notice letters, and staff interview, the facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) to residents. This affected two residents (#24 and #104) of three residents reviewed for Medicare beneficiary notice letters. The census was 51.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included minimum healthcare information necessary to properly care for the immediate needs for one resident (#259) of one resident reviewed for baseline care plans. The facility census was 51.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement a comprehensive care plan to include all aspects of patient care. This affected one (Resident #1) of 16 residents reviewed for comprehensive care plans. The facility census was 51.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to provide treatment for contracture's. This affected one (Resident #1) of one reviewed for contracture's. The facility also failed to provide treatments per physician order. This affected one (Resident #259) of one reviewed for treatments. The facility census was 51.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure an ordered safety intervention was in place for a resident. This affected Resident #21 of four reviewed for accidents. The census was 51.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to ensure oxygen tubing was changed per physician order. This affected three (Residents #7, #22, and #23) of five residents reviewed for oxygen. The facility census was 51.

Inspectors wroteBased on medical record review, staff interview, and review of information from Medscape, the facility failed to follow pharmacy recommendation for one resident (#25) of five reviewed for unnecessary medications resulting in an unobserved medication error. The facility census was 51.

Inspectors wroteBased on record review, staff interview, policy review and review of medication information from Medscape, the facility failed to ensure a resident was free from unnecessary medications regarding having an adequate indication of use for a long-term antibiotic. This affected one (#40) out of five resident reviewed for antibiotic stewardship. The facility census was 51.

Inspectors wroteBased on observation, Novolog insert, and staff interview, the facility failed to ensure insulin pen was primed resulting in a significant medication error. This affected one resident (#15) of one reviewed for insulin administration. The facility census was 51.

Inspectors wroteBased on observation, staff interview, and scoop size chart, the facility failed to follow the menu for pureed diets. This affected three residents (#02, #04, and #35) identified by the facility as receiving a puree diet. The facility census was 51.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure proper infection control practices during medication pass. This affected two residents (#1 and #15) of four residents reviewed for medication administration. The facility census was 51.

Inspectors wroteBased on record review, staff interview, policy review, and review of information from Medscape, the facility failed to conduct ongoing review for antibiotic stewardship. This affected one (#40) out of five resident reviewed for antibiotic stewardship. The facility census was 51.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, observation, staff interview and review of facility of policy, the facility failed to provide care for a resident's intravenous access. This affected one (#15) of one residents reviewed in the sample for IV access. The census was 53.

Inspectors wroteBased on medical record review, staff interview, review of Self Reported Incident (SRI) and facility policy, the facility failed to perform a thorough investigation regarding an allegation of sexual abuse. This affected one (#6) out of one SRI's reviewed. The facility identified one SRI in the last six months. Facility census was 48.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a resident was free from unnecessary medications when staff failed to administer blood pressure medications in accordance with the blood pressure parameters ordered by the physician. This affected one (#25) of five residents reviewed for unnecessary medications. The census was 48.