Adel Acres: Antibiotic and Diabetes Care Failures - IA
That finding is documented in a complaint inspection completed October 16, 2025.
The trouble began in mid-July. The resident had a PICC line, a type of intravenous catheter threaded into a large vein, and pulled it out. A peripheral IV was placed in the right wrist on July 19. The resident removed that one too. Nurses notes from July 22 show the IV antibiotic was not administered at 1:28 AM or at 11:15 PM because there was no IV access. Neither entry documents that a physician was notified.
The antibiotic had been ordered for five days. The medication administration record for July showed it was given once, on July 19.
On July 23, staff finally contacted the provider to clarify orders. The IV antibiotic was discontinued and an oral antibiotic was substituted. The next day, July 24, staff called the provider again, this time because the resident was experiencing what the nurses notes described as "electrifying pain" when the area around a drain tube insertion site was touched, and the pocket above the site had filled with fluid. The resident was sent to the hospital.
The hospital discharge summary recorded sepsis and a worsening retroperitoneal abscess, an infection in the deep tissue behind the abdominal cavity.
The resident's own physician, identified in the inspection report as Staff N, told inspectors on October 16 that she had given an admission order on June 12 for blood sugar checks before meals and at bedtime to monitor the resident's diabetes. She said she would have expected the facility to follow through with the order. She told inspectors that if blood sugar had been monitored as ordered, "would have been less likely for the BS to be so high, as would have provided earlier treatment if required and would have been better overall for the resident's health."
The blood sugar monitoring had not been followed as ordered.
A lab report from August 18 showed a glucose level of 328, well above the normal range of 70 to 99. A September 2 lab report showed a hemoglobin A1C of 9.8. The A1C measures average blood sugar over the previous two to three months. The action threshold is 8.0. The goal of therapy was listed as below 7.0.
By September 15, the resident's blood sugar had reached 554. Staff checked again thirty minutes later. It had climbed to 600. The resident was sent to the hospital that night, urgent, to rule out sepsis.
After the resident returned, orders were in place requiring staff to notify the provider any time blood sugar exceeded 401. The medication administration record for September documented five separate readings above that threshold, none of them accompanied by any documented notification to the physician.
On September 20 at 11 AM, the blood sugar was 513. On September 21, it was 407 at 2 AM, 429 at 11 AM, and 432 at 5 PM. On September 30, it was 406. The order said to call the doctor. The record shows no one did.
Two nurses interviewed by inspectors described, in their own words, what they would do if a resident arrived with a diabetes diagnosis and no insulin orders: call the provider, check with the transferring facility, and do a blood sugar check. Both described it as standard practice. Neither was asked to explain why the orders already in place for this resident hadn't been followed.
The physician put it plainly. If the blood sugar had been monitored as she ordered back in June, the resident would have had a better chance.
The resident was hospitalized twice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adel Acres from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
Adel Acres in Adel, IA was cited for violations during a health inspection on October 16, 2025.
That finding is documented in a complaint inspection completed October 16, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.