Adel Acres
Adel Acres in Adel, IA — inspection on March 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Electronic Health Record (EHR) for Resident #10 revealed a physician order dated 12/8/25 to weigh resident daily, notify physician of changes in weight (3 pounds in 1 day or 5 pounds in 7 days), obtain prior to eating and drinking and send to clinic for review.
Review of the March 2026 Medication Administration Record (MAR) for Resident #10 revealed the following weight changes:a. On March 18th, weight of 172.3 pounds.b. On March 19th, weight of 165.7 pounds, a change of 6.6 pounds in one day. c. On March 20th, weight of 170.7 pounds, a change of 5 pounds in one day. d. On March 23rd, weight of 169.6 pounds.e. On March 24th, weight of 173.9 pounds, a change of 4.3 pounds in one day.
Review of the EHR for Resident #10 revealed a lack of documentation to reflect the physician was notified of the weight changes as indicated in the parameters of the order dated 12/8/25.
During an interview on 3/26/26 at 4:29 PM, the Director of Nursing (DON) stated the facility did not notify the physician regarding the weight changes for Resident #10 in March as required under the order by the physician for weight changes.
The DON acknowledged the facility should have notified the physician of the weight changes according to the physician order and acknowledged they did not follow the physician orders.
The DON stated an expectation that physician orders are followed.
Review of the facility policy Provision of Physician Ordered Services, undated, documented the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
165555 03/26/2026
Adel Acres 1919 Greene Street Adel, IA 50003
During an interview on 3/26/26 at 11:55 AM, Staff E reported they provided Resident #35 with three 15mg Oxycodone HCl tablets the morning of 3/25/26.
Staff E acknowledged they did not look at the medication administration card or the dose of the tablets.
Staff E explained the shift before they provided 3 tablets to the resident.
Staff E stated there is no formal process in place to track or check the specific dose of pills with new medication administration cards compared to previous cards.
During an interview on 3/26/26 at 1:00 PM, Staff H, RN for Resident #35's Primary Care Provider (PCP), reported they were at the facility the afternoon of 3/25/26, approximately 4:00 PM. At this time, Resident #35 was responding to verbal stimuli but was drowsy.
The resident's right arm was contracted at the elbow and was holding it up.
Their left hand was shaky.
Pupils were assessed as pinpoint.
Vitals obtained and were stable.
Staff H reported Resident #35 was not right and the PCP was contacted via Telehealth visit.
The PCP initially believed symptoms were possibly related to one of the following: 1.
Overdose with the need for Narcan use (would need to send out to the hospital if used); 2.
Not tolerating current use of opioids; or 3.
Transient ischemic attack/mini stroke (would need to send out to the hospital). Resident #35's son was present throughout.
After further discussion, the decision was made to keep the resident at the facility to observe.
Approximately 45 minutes later, Resident #35 was more alert, not shaky.
Orientation was at the resident's baseline.
They were up in a wheelchair and ready for the evening meal.
When Staff H left the building for the evening, they were under the impression Resident #35 had received the prescribed Oxycodone HCl dose of 15mg for the morning and noon administrations on 3/25/26.On 3/26/26 at 7:20 AM, Staff H stated the facility had contacted them to inform of the medication error the day before.
Staff H contacted the PCP with new orders to hold any further oxycodone administrations.
The PCP completed a Major Injury Determination Form and determined the event to be a major injury.
The PCP noted Resident #35's prognosis as guarded due to their underlying medical conditions of severe dementia with behavioral disturbance, congestive heart failure, chronic kidney disease and oxygen dependent.
The resident noted with opioid dependence.
During an interview on 3/26/26 at 1:15 PM, the DON explained staff should and would expect them to compare medication administration cards to the MAR to ensure the correct medications were provided.During in interview on 3/26/26 at 2:00 PM, Staff I, RN, explained during medication administrations, the six rights should be followed to ensure accuracy.
Staff I noted there is no formal process in place to notify staff when there is a dose change with new, incoming medication administration cards.
Staff I stated when they are aware of such a situation, they would try to alert oncoming staff of the change.
The policy Administering Medications, version 2.0 (H5MAPL0028), outlined the following:1.
Individuals administering medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route before giving.2. As required or indicated for a medication, the individual will record in the resident's medical record the date/time of the administration, the dosage, route, any complaints/symptoms, any results, and the name/title of the individual administering.
165555 03/26/2026
Adel Acres 1919 Greene Street Adel, IA 50003
During an interview on 3/25/26 at 2:35 PM, the Registered Dietitian (RD) explained staff should be following the volume method to determine the correct scoop size and serving sizes.
The RD acknowledged and confirmed Staff I did not measure out the puree meat to establish what scoop size to use.
The RD noted there should not have been a serving size of the puree meat after lunch service if the correct scoop utilized.The policy Pureed Diet Policy & Procedure, revised January 2024, outlined the following: 1.
Add the correct number of servings of food to the food processor 2.
Puree until the proper final consistency is reached 3.
Pour the food into a clear volume measure cup and determine the final volume 4.
Use chart to determine serving size 5. If chart not available or the final volume is too small, convert the volume to ounces and divided by the number of servings started to determine serving size 6.
Cover, label with serving size, and place in appropriate hot or cold area
165555 03/26/2026
Adel Acres 1919 Greene Street Adel, IA 50003
food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas