Adel Acres

In the surveyor’s words

From the most serious findings on record at Adel Acres, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 26, 2026

  Based on clinical record review, observation, written staff statement, personnel file review, staff interviews and policy review, the facility failed to provide adequate nursing supervision for 1 of 3 residents reviewed (Resident #1), which resulted in a resident falling from the bed to the floor, causing the resident significant pain and injuries. The facility reported a census of 41 residents.Findings include:The Minimum Data Set (MDS), dated [DATE], documented Resident #1 had diagnoses to include stroke, arthritis, aphasia (a neurological disorder caused by brain damage that impairs a person's ability to speak, write, and understand language) and hemiplegia (paralysis of one entire side of the body) affecting the right dominant side. […]

• Actual harm, isolatedF760Mar 26, 2026

  Based on clinical record review, facility document review, staff interviews, and policy review, the facility failed to ensure a significant medication error did not occur for 1 of 5 residents reviewed for medication administration. Resident #35 received one dose of 25 milligram (mg) Oxycodone HCl (an opioid narcotic used for pain management) and two doses of 45mg Oxycodone HCl when Physician Orders stated to administer 15mg. The facility reported a census of 40.Findings include:The Minimum Data Set (MDS) Assessment completed on 3/10/26 revealed Resident #35 with a Brief Interview for Mental Status score of 8, indicating a moderate cognitive impairment. Diagnoses include anxiety, chronic obstructive pulmonary disease, depression, heart failure, and respiratory failure. […]

• Actual harm, isolatedF658Oct 16, 2025

  Based on clinical record review, staff interviews, and policy review the facility failed to follow the physician's order to complete blood sugar (BS) checks and administer intravenous (IV) antibiotics for a resident with diabetes and an infection and failed to notify the physician when an IV antibiotic was not available/or able to be administered for 1 (Resident #1) of 3 residents reviewed. The resident was re-hospitalized for sepsis and had high blood sugars. The facility reported a census of 42 residents. Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/9/25, included diagnoses of diabetes, septicemia (presence of bacteria in the blood stream), renal (kidney) failure, and aphasia (impairment in a person's ability to comprehend or formulate language). […]

• Actual harm, isolatedF684Oct 16, 2025

  Based on electronic health record review, document review, family and staff interviews, and policy review, the facility failed to promptly identify and intervene for a change in a resident's condition after falls for 2 of 3 residents reviewed for assessment and intervention (Residents #3 and #4). The facility reported a census of 42.Findings include:1. The Minimum Data Set (MDS) assessment completed 5/19/25 revealed Resident #4 with a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Diagnoses include anxiety disorder, frontal lobe and executive function deficit, hemiplegia (affecting right dominant side), schizophrenia, and stroke. […]

• Actual harm, isolatedF684Apr 9, 2025

  Based on clinical record review, observations, family and staff interviews, and policy review, the facility failed to ensure nursing staff completed weekly assessments and provide timely intervention (resulting in worsening of skin impairment) when a resident exhibited a change in skin condition for 1 of 3 residents reviewed for skin concerns or had a change in condition (Resident #30), and failed to document if oxygen provided to a resident when the resident's oxygen saturations dropped below the physician's ordered parameters for 1 of 3 residents reviewed for oxygen (Resident #30). The facility reported a census of 44 residents. […]