Adel Acres

F 0658 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

pharmacy to see when it was going to be available and if unable to administer an IV antibiotic, she would notify the physician.Interview on 10/16/25 at 2:00 PM, Staff N, Primary Care Physician stated an admission order was given on 6/12/25 for a BS at AC and HS to monitor resident's diabetes. Staff N stated she would have expected the facility to follow through with the order. Staff N further stated if the BS 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, as the resident was sent to the hospital with a BS that was not responding to treatment and possible infection.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Adel Acres

1919 Greene Street Adel, IA 50003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

pain, and the range of motion. Staff O further stated if the resident assistance requirements increased and complaining of pain she would notify the physician and not move the resident around, with all assessments documented.

Interview on 10/14/25 at 11:15 AM, Staff O stated she didn't recall any nurse asking her to assess Resident #3 on 8/11/25. Staff O stated she came to work about 7:00 AM and was talking with the DON regarding the resident's falls on the 24-hour report, and was trying to figure out if the resident had 1 or 2 falls. Staff O stated she assessed the resident with the DON later in the morning and noted a bruise to the resident's right hip. Staff O further stated when a resident falls do a full head to toe assessment, vital signs, check range of motion, look for rotation of legs, and document all. Staff O stated then need to observe everything

on the resident, do neuro checks per policy, complete and document a fall follow-up every shift for 72 hours and if the staff are reporting the resident is having pain and requiring increased assistance would do a full assessment, notify the physician for possible x-rays, and provide pain medication if available.

Interview on 10/14/25 at 3:45 PM, the DON stated she wasn't aware of Resident #3's falls and after she came in on 8/11/25 was the first she heard of the resident's pain and not bearing weight. The DON stated

she thought it was at the 9:30 AM morning meeting that she was notified by therapy and a CNA, therapy told her the resident was complaining of pain and the left hip, staff told her was the resident's right hip and

he was not bearing weight on his right leg. The DON stated noted a bruise on the resident's right hip and

she called the physician who ordered an x-ray and the facility got the results of a hip fracture later that morning while the physician was in the building and the resident was then sent out via ambulance to the hospital.

Resident #3's hospital Summary of Care dated with admission date of 8/11/25 revealed an x-ray report, dated 8/11/25, with a mildly displaced right intertrochanteric (hip) fracture in moderate varus (body part angles inward) malalignment and documented a right hip replacement surgery completed.

Facility's Healthcare Fall Management Program dated 10/14/24 revealed follow-up documentation should be completed every shift for at least 72 hours after the fall and should include: neuros (if applicable), vital signs, pain, and range of motion.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Adel Acres

1919 Greene Street Adel, IA 50003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provider's nurse in the facility, spoke with her, and she stated she will contact the doctor to return call.10/9/25 2:13 PM - Resident's BS faxed to provider.10/10/25 1:27 AM - Insulin dosage order changed for hour of sleep.Interview on 10/8/25 at 8:15 AM, Staff A, Licensed Practical Nurse (LPN) works full time and stated provider is very difficult. The provider does not return calls for 2-3 days. If it is something critical,

she would notify the Medical Director. If she receives new labs with abnormal results, will call the provider, and if the provider does not call back by the end of her shift, she will call again. Staff A stated she does document in the resident's chart if the provider is notified and if new orders or no new orders from the lab results. Further stated the provider will call the pharmacy and order medications, medications are delivered, and unaware of the new medication order, so will have to call the provider and get the new order. Also, sometimes the provider will order x-rays, and get the x-ray report and the facility doesn't, so the facility doesn't know the report is back and will have to call the provider to get the x-ray report. Interview on 10/13/25 at 3:45 PM, the Director of Nursing (DON) stated the provider usually does all orders via email and fax. The DON stated it varies with a response time for return calls from the provider. Stated she has read different residents' progress notes that state the provider hadn't returned a call or several hours later

before returned the call. The DON stated if was an urgent call, she would expect a return call within 5 - 10 minutes, but return calls from the provider have not been very good. The DON further stated she placed a call to the provider with a resident's BS of 600 and the connection was poor and not able to understand the conversation, and then the call ended and the provider did not call back. The DON further stated there are problems with who is the point of contact for the provider and the facility set up a meeting with the provider to discuss things and the facility had to cancel the meeting so was going to set up another meeting with the provider. Interview on 10/16/25 at 12:45 PM, Staff O, LPN/MDS Coordinator stated the provider is hard to work with, does not return calls. Staff O stated she calls the transition nurse care manager during business hours when the provider does not return a call and after hours if the provider did not return a call, she would call back consistently if it was urgent till she gets the provider, or would call the Medical Director.Facility Physician Services policy, reviewed on 4/28/22, revealed the Physician and/or Nurse Practitioner will supervise the medical care of the resident by, but not limited to monitor changes in the resident's medical status, provide consultation/treatment based on the resident's condition, and a physician will be available 24 hours/day for the provision or the arrangement of emergency care.

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Facility ID:

If continuation sheet