Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ballard Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering exited the facility through a back door after following a construction worker. Staff did not promptly notice or report the resident's absence, and the resident was found several blocks away before being returned. The facility's elopement policy was not followed, and staff acknowledged the incident was preventable.
The facility failed to maintain a clean and safe environment, with multiple areas observed to have black residue, strong urine odors, missing floor tiles, and peeling material on walls and ceilings. Despite staff claims of daily cleaning, significant lapses were noted, affecting the safety and comfort of residents.
The facility failed to conduct a thorough investigation into an abuse allegation involving a cognitively impaired resident. Despite suspending and terminating the employee involved, the facility did not document required interviews with the resident, witnesses, or other staff members, nor could they locate the witness statement.
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. The resident reported that the facility did not send or receive communication forms to and from the dialysis center, and staff did not assess their dialysis port before or after treatments. The DON confirmed the lack of proper documentation and communication, highlighting the facility's failure to provide safe and appropriate dialysis care.
The facility failed to ensure medications were administered as ordered for a resident with heart failure, hypertension, and diabetes. Multiple instances were documented where medications were given outside the prescribed time frames, and blood pressure medication was administered despite not meeting the required heart rate parameter. The DON and a CMA confirmed the proper protocols were not followed.
The facility failed to maintain kitchen cleanliness and repair, affecting 51 residents, including two on feeding tubes. Observations included lint on vents, missing wall tiles, residue in machines, and improper storage of items on the floor. The DM confirmed these issues and stated that the kitchen was cleaned daily and maintenance concerns were logged.
The facility failed to follow infection control measures during fingerstick glucose monitoring for nine residents. An LPN did not perform hand hygiene before and after wearing gloves, did not disinfect glucometers between uses, and did not cleanse residents' fingertips prior to piercing the skin. The corporate nurse consultant and DON confirmed these deficiencies.
The facility failed to educate, offer, and screen two residents for eligibility to receive pneumococcal and influenza vaccinations, and did not document consent or declination in their medical records, as required by facility policies.
A resident with moderate cognitive impairment and a diagnosis of depression was found with a tablet on their over-the-bed table without a physician order to self-administer medications. An LPN confirmed the resident did not have such an order and identified the tablet as likely being the resident's trazodone.
The facility failed to ensure that call lights accommodated the needs of two residents with moderately impaired cognition and physical impairments, requiring them to rely on their roommates to activate the call lights.
The facility failed to ensure a resident's code status was accurately documented. A resident with multiple diagnoses had a signed DNR order on file, but a physician order documented CPR, and an LPN incorrectly identified the resident as a full code despite the resident's clear statement that they did not want CPR. The discrepancy was confirmed when the LPN was shown the signed DNR in the resident's EHR.
The facility failed to update the care plan for a resident admitted to hospice services. Despite a physician order and a significant change assessment indicating the need for hospice care, the care plan was not updated until an audit revealed the oversight months later. The resident had severe cognitive impairment and required assistance with most ADLs.
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay for one of three sampled residents reviewed for discharge. The discharge summary did not document a diagnosis on discharge or a summary of the course of treatment. The corporate nurse consultant stated that the nurse should have filled out the recapitulation of stay portion of the discharge summary.
A resident with anxiety was prescribed buspirone but the facility failed to document monitoring for side effects from December to March, as confirmed by a corporate nurse consultant.
Failure to Prevent Elopement of Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment and a known history of wandering. The resident, who had diagnoses including Alzheimer's, dementia, difficulty walking, muscle weakness, heart failure, anxiety, acute kidney failure, and repeated falls, was identified as an elopement risk on their care plan. Despite this, the resident was able to exit the facility through a back door, reportedly following a construction worker, and was not immediately noticed as missing by staff. Staff interviews revealed that the resident was not present at dinner, and it was only after searching and being notified by construction workers that the absence was recognized. The resident managed to get approximately three blocks away before being located and returned to the facility. The facility's elopement policy required prompt reporting and intervention when a resident was suspected of leaving or missing, but staff failed to follow these procedures. There was confusion among staff regarding the resident's whereabouts, and the incident was not reported in a timely manner. Additionally, it was noted that during certain facility activities, such as fire drills or door testing, doors became unlocked, potentially contributing to the resident's ability to leave undetected. The director of nursing and other staff acknowledged that the resident was at risk for harm and that the elopement was preventable.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure the physical environment was kept clean and maintained in good repair, affecting the safety and comfort of its residents. Observations revealed multiple areas with black residue, strong urine odors, missing floor tiles, and peeling material on walls and ceilings. Specifically, the women's visitor/staff restroom, several shower rooms, and resident restrooms were found to have black residue on the toilet bowls and floors. Additionally, the laundry room had an accumulation of lint and unfinished sheetrock near the window air unit. These conditions were confirmed by the housekeeping/laundry supervisor and the COO, administrator, and corporate nurse consultant. The facility's policy titled 'Homelike Environment' was not adhered to, as it mandates a clean, sanitary, and homelike setting. Despite staff claims of daily cleaning and reporting maintenance concerns, the observations indicated significant lapses in maintaining a clean and safe environment. The presence of gnats, missing floor drain covers, and unsealed sheetrock further highlighted the facility's failure to provide a safe and comfortable environment for its residents.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident diagnosed with nontraumatic intracerebral hemorrhage and dysphagia following cerebral infarction. The resident was severely cognitively impaired and required assistance with most ADLs. An incident was reported where a CMA observed the resident kissing a facility employee. The employee was suspended and later terminated after confessing to the allegation. However, there was no documentation of a comprehensive investigation as required by the facility's abuse policy, which mandates interviews with the resident, witnesses, other staff members, and a review of all events leading up to the incident. The administrator confirmed that while camera footage was reviewed and the appropriate agencies were notified, the facility did not document interviews with the resident, additional residents, or other staff members. Additionally, the witness statement from the CMA who observed the incident could not be located. This lack of thorough documentation and adherence to the facility's abuse investigation policy constitutes a deficiency in handling the abuse allegation properly.
Failure to Ensure Proper Dialysis Monitoring and Communication
Penalty
Summary
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease, had physician orders to obtain weight before and after dialysis on specific days. However, the resident reported that the facility did not send or receive communication forms to and from the dialysis center. Additionally, the resident stated that staff did not assess their dialysis port before or after treatments, and the only people involved with their dialysis port were from the dialysis center. The Director of Nursing (DON) confirmed that communication forms were rarely returned and were not present in the resident's chart. The DON also admitted that the only assessment related to dialysis was obtaining the resident's weight before and after treatment. Further investigation revealed that there was no documentation in the resident's chart for an order to monitor or send the resident to dialysis. The DON acknowledged that there had never been an order for dialysis in the resident's chart, despite the resident's need for such treatment. The lack of proper documentation, communication, and assessment highlights the facility's failure to provide safe and appropriate dialysis care for the resident.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident with diagnoses including heart failure, hypertension, and diabetes. The resident had specific physician orders for insulin aspart, metoprolol tartrate, insulin detemir, Lantus, and Humalog. The Medication Administration Records (MAR) for February and March 2024 documented multiple instances where medications were administered outside the prescribed time frames. Specifically, metoprolol was administered five times when the resident's heart rate was less than 65, contrary to the physician's order to hold the medication in such cases. Additionally, insulin aspart, insulin detemir, Lantus, and Humalog were frequently administered more than one hour after the scheduled times, with some medications being delayed up to 12 times in a month. On March 26, 2024, the Director of Nursing (DON) confirmed that medications should be administered no later than one hour before or after the scheduled time. A Certified Medication Aide (CMA) also stated that blood pressure medications should have been held if the heart rate parameter was not met and that the nurse should have been notified, with actions documented in the resident's chart. These failures indicate a lack of adherence to physician orders and proper medication administration protocols, leading to the identified deficiency.
Kitchen Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was kept clean and maintained in good repair, affecting 51 residents who received services from the kitchen, including two residents who relied solely on feeding tubes for nutrition and hydration. During a tour of the kitchen, several deficiencies were observed: lint on ceiling vents and surrounding areas, accumulation of lint on a floor fan, missing wall tiles behind the stove, holes and peeling material below the three-compartment sink, a baseboard tile pulling away from the wall near the back door, visible gaps and daylight under the back door, missing baseboards in the dish machine area, white residue on and in the dish machine, black residue inside the ice machine and on the floor under equipment, and improper storage of foam cups and multiple boxes of supplements and juice on the floor in the dry storage area. Additionally, the baseboard was missing in the employee storage area. The Dietary Manager (DM) confirmed these observations and stated that the kitchen was cleaned daily and maintenance concerns were recorded in a log. The DM also acknowledged that food and single-service items should be stored off the floor.
Infection Control Deficiency During Fingerstick Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection control measures during fingerstick glucose monitoring for nine residents. The observations revealed that the LPN did not perform hand hygiene before and after wearing gloves, did not disinfect the glucometers between uses, and did not cleanse the residents' fingertips prior to piercing the skin with a lancet. These actions were contrary to the facility's policy, which required hand hygiene, disinfection of equipment, and cleansing of the fingertip before the procedure. During the observation, the LPN was seen performing fingerstick glucose monitoring on multiple residents without adhering to the infection control protocols. The LPN did not perform hand hygiene after removing gloves and before donning new ones, and the glucometers were not disinfected between uses. Additionally, the LPN did not cleanse the residents' fingertips before obtaining blood samples, which is a critical step to prevent infection. The corporate nurse consultant and the Director of Nursing (DON) acknowledged the deficiencies in the LPN's practices. They confirmed that the LPN should have performed hand hygiene before and after each procedure, disinfected the glucometers between uses, and cleansed the residents' fingertips prior to piercing the skin. The DON stated that the use of two glucometers was intended to allow proper disinfection and drying time between residents, which was not followed by the LPN.
Failure to Educate, Offer, and Document Vaccinations
Penalty
Summary
The facility failed to educate, offer, and screen residents for eligibility to receive the pneumococcal and influenza vaccinations. Specifically, one resident was not screened for eligibility, nor provided with education regarding the risks, benefits, and side effects of the pneumococcal vaccine. Additionally, there was no documentation of consent or declination for this vaccination in the resident's medical record. Another resident was not screened for eligibility, nor provided with education regarding the risks, benefits, and side effects of the influenza vaccine. Similarly, there was no documentation of consent or declination for this vaccination in the resident's medical record. The facility's policies for pneumococcal and influenza vaccinations, revised in April 2012, require that residents be assessed for vaccination status within five working days of admission, provided with education, and that this education be documented in the medical record. The policies also state that vaccinations should be administered unless medically contraindicated, already given, or refused, with refusals documented in the medical record. The Director of Nursing confirmed that no documentation could be located for the two residents in question, indicating a failure to follow these policies.
Failure to Ensure Physician Order for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident had a physician order to self-administer medications. Resident #37, who had a diagnosis of depression and a physician order for trazodone HCL 100 mg at bedtime, was observed with a round white tablet in a clear medicine cup on their over-the-bed table. The resident, whose cognition was documented as moderately impaired, stated they did not know what the tablet was or how it got there. An LPN confirmed that the resident did not have a physician order to self-administer medications and identified the tablet as likely being the resident's trazodone. The LPN subsequently removed the medicine cup from the resident's room.
Failure to Accommodate Resident Needs with Call Lights
Penalty
Summary
The facility failed to ensure that call lights accommodated the needs of two residents, both of whom had moderately impaired cognition and physical impairments. Resident #10, who had rheumatoid arthritis and type 2 diabetes mellitus, was unable to use their call light because it required holding down a button to keep it activated. This resident had to rely on their roommate to activate the call light. Similarly, Resident #37, who had peripheral vascular disease and other unspecified symptoms, also had to hold down the button on their call light to keep it activated. This resident sometimes had to rely on their roommate to activate the call light as well. Interviews with CNAs and a corporate nurse consultant revealed that the facility used two types of call lights: one that stayed on when the button was pushed down and another older type that required holding the button down to keep it activated. Both CNAs confirmed that the residents in question were using the older type of call light, which they were unable to operate independently. The corporate nurse consultant was unaware of the existence of the older call lights and believed that only the newer type was in use. This lack of awareness and the presence of outdated call lights led to the deficiency in accommodating the residents' needs.
Failure to Ensure Accurate Code Status Documentation
Penalty
Summary
The facility failed to ensure a resident's code status was accurately documented. Resident #21, who had diagnoses including COPD, HTN, major depressive disorder, hyperlipidemia, osteoarthritis, PTSD, and chronic pain, had a signed DNR order on file. However, a physician order documented CPR, and an LPN incorrectly identified the resident as a full code despite the resident's clear statement that they had signed a DNR and did not want CPR. The discrepancy was confirmed when the LPN was shown the signed DNR in the resident's electronic health record (EHR).
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to update the care plan for a resident who was admitted to hospice services. The resident had diagnoses including Alzheimer's disease, dementia, and congestive heart failure. A physician order dated 10/31/23 documented the admission to hospice services due to congestive heart failure. A significant change assessment on 11/10/23 noted the resident was severely cognitively impaired and required partial to moderate assistance with most ADLs, and was receiving hospice services. However, the care plan, which was initiated on 03/24/24, did not include hospice services until an audit on 03/24/24 revealed the oversight. The MDS coordinator confirmed that the care plan should have been updated at the time of the hospice admission in October 2023 but was not.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay for one of three sampled residents reviewed for discharge. Resident #55 was discharged from the facility on 03/01/24. The discharge summary, dated 03/01/24, did not document a diagnosis on discharge or a summary of the course of treatment in the facility. On 03/26/24 at 1:32 p.m., the corporate nurse consultant stated that the nurse should have filled out the recapitulation of stay portion of the discharge summary.
Failure to Monitor Antianxiety Medication Side Effects
Penalty
Summary
The facility failed to ensure that an antianxiety medication was monitored for effectiveness and side effects for one of the five sampled residents reviewed for unnecessary medications. The resident had a diagnosis of anxiety and was prescribed buspirone 10 mg three times per day starting on December 7, 2023. A subsequent physician order on March 24, 2024, required monitoring for side effects of the antianxiety medication. However, upon review, it was found that there was no documentation of side effect monitoring from December 7, 2023, to March 24, 2024. This was confirmed by a corporate nurse consultant who stated there was no documentation available for that period.
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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 | 1.6 mi | — | 0 | 0 |
| Ada Care Center | 1.6 mi | — | 0 | 0 |
| Callaway Nursing Home | 24.4 mi | — | 1 | 0 |
| Artesian Home | 25.4 mi | — | 0 | 0 |
| Heritage Village Nursing Home | 27 mi | — | 9 | 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 August 2026) and official state health department websites.