Adelphi Nursing and Rehabilitation Center

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure Residents had a dignified existence. This was found to be evident for 5 (Resident #88, #8, #163, #21, and #7) out of 32 Residents observed for dignity during the recertification and compliant survey.

Inspectors wroteBased on observations, record review and interview, it was determined that the facility failed to 1) ensure Resident belongings were safe and secure. This was evident for 3 (Resident #30, #38, and #120) of 3 residents and 2) provide a safe comfortable and homelike environment. This was evident for resident 2 (Resident #59, and #10) out of 2 residents reviewed for Resident Rights during the recertification and compliant survey process.

Inspectors wroteBased on medical record reviews and interviews it was determined that the facility failed to obtain consent for Psychotropic Medication administration. This was evident for 2 (#9 and #3) of 5 residents reviewed for Psychotropic Medications during the recertification survey.

Inspectors wroteBased on medical record review and interviews with resident and facility staff, it was determined that the facility failed to invite a resident to their care plan meetings. This was evident for 1 (Resident #138) out of 2 residents reviewed during recertification survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure a Resident's needs were accommodated. This was found to be evident for 1 (Resident #126) out of 8 Residents reviewed for accommodation of needs during the recertification and complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that residents were free from abuse. This was identified during review of facility-reported incident #2731067 and was evident for 2 (Resident #104 and #161) out of 2 residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews it was determined the facility failed to notify the resident in writing of the bed hold policy when the resident was transferred from the facility to a hospital. This was evident for 1 (resident #6) of 2 residents reviewed for hospitalization during the recertification survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure that a Resident received an assessment for additional services. This was found to be evident for 1 (Resident #7) out of 1 Resident reviewed for PASRR evaluation during the recertification and complaint survey.

Inspectors wroteBased on record review and interview, the facility failed to initiate a baseline care plan for Resident #163, as required. This was evident for 1 (Resident #163) out of 1 resident reviewed during the recertification survey.

Inspectors wroteBased on medical record reviews and interview, it was determined that the facility failed to 1) initiate care plans based on medication use. 2) care plan for house acquired pressure ulcer for a resident. This was evident for 2 (Resident# 101 and #120) out of 2 residents reviewed during a recertification survey.

Inspectors wroteBased on interviews and medical record reviews it was determined that the facility failed to have quarterly care plan meetings with the interdisciplinary team. This was found to be evident for 1 (Resident #15) out of 6 Residents reviewed for care plan meetings during the recertification survey.

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to provide ongoing resident-centered activities to meet residents' interests and needs. This was evident for 1 resident (Resident #2) out of 3 residents reviewed for the personalized activities during the annual survey. On 04/02/26 at 2:24 PM, observed Resident #2 was sitting in bed alone in the room. The resident was able to engage in conversation and move her upper extremities freely; however, no activity materials or devices were found at the bedside. During an interview, the resident confirmed that no such materials or device had been provided and expressed an interest in receiving them. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility staff failed to provide sufficient Foley catheter monitoring, standard care and documentation per shift. This was evident for 1 (Resident #11) of 3 residents reviewed for bowel and bladder incontinence during the annual survey.

Inspectors wroteBased on record review and interview, the facility failed to provide a minimum of 3 hours of bedside care, per occupied bed, per day. This was evident for 3 out of 14 days reviewed during the annual recertification survey.

Inspectors wroteBased on observation of medication administration and review of medical records it was determined that the facility failed to ensure a medication error rate of less than 5%. This was evident for 2 medication administration errors out of 27 medication administration opportunities observed which resulted in a medication error rate of 7.41% during the recertification survey.

Inspectors wroteBased on observation and interviews, it was determined the facility failed to ensure medications were properly labeled, stored, and wasted. This was evident for 3 of 3 medication carts observed, 1 of 2 medication storage rooms observed, and 1 Resident (Resident #59) of 5 Residents observed during the recertification survey and complaint survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to maintain the food prepared and storage areas in a sanitary manner, which includes keeping the kitchen free from contaminants and physical hazard free. This was evident for 1 out of 1 kitchen tours during the annual survey and has the potential to affect all residents. On 04/02/2026 at 8:23 AM, in kitchen area personal items of cell phone, keys and drinks were observed on a tray cart outside the refrigerator area. The Kitchen Manager (Staff #13) noted that lockers are available for staff use immediately outside the kitchen. However, subsequent observations on 04/06/2026 at 12:37 PM confirmed that personal items continue to be left in storage and food preparation areas. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop a care plan to address how staff should care for and monitor a resident's pacemaker for 1 (Resident #16) of 4 sampled residents reviewed for a pacemaker.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure licensed nursing staff had orders to monitor a resident's pacemaker for proper functioning for 1 (Resident #6) of 4 sampled residents reviewed for a pacemaker. The facility further failed to ensure staff reported a resident's fall to the licensed nursing staff so that an assessment of the resident could be done before the resident was picked up from the floor for 1 (Resident #13) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to document a behavioral incident in the medical record of 1 (Resident #8) of 16 sampled residents. The facility further failed to ensure a nurse did not transcribe a medication order to a resident's medication administration record (MAR) that was not prescribed to the resident for 1 (Resident #2) of 16 sampled residents.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide maintenance services necessary to maintain a clean, comfortable, and homelike environment. This was observed in 1) 4 resident rooms (#125, #128, #201, and #204) of 68 rooms and 2) 19 (2nd floor room [ROOM NUMBER] to 233) rooms identified with poor interior wall paint integrity out of 29 residents' room reviewed.

Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to provide treatments according to a resident's plan of care. This was found evident of 4 (Resident #134, #34, #121, & #69) out of 5 residents reviewed for skin care.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure nursing staff were competent in medication administration. This was found to be evident in 21 (LPN 19, LPN 33, LPN 34, LPN 35, RN 36, LPN 37, LPN 38, LPN 39, RN 40, LPN 41, LPN 42, LPN 43, RN 44, LPN 45, LPN 46, LPN 47, RN 48, RN 49, LPN 50, LPN 51, LPN 52) of 59 licensed nursing staff employees reviewed for medication administration record (MAR) documentation during the recertification survey.

Inspectors wroteBased on observations of the facility's kitchen, and staff interviews, it was determined that the facility failed to store items properly to maintain the integrity of specific food items and utensils under sanitary conditions. This was evident for one of three observations during kitchen tours on the annual survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to notify the resident's health care Responsible Party (RP) of a change to the resident's plan of care. This was found evident in 3 (Resident #4, #50 and #69) of 70 residents reviewed during the survey.

Inspectors wroteBased on observation and staff interview it was determined facility staff failed to ensure a resident assessed to need a mobility device had access to the device. This was evident for 1 (Resident #69) of 5 residents reviewed for accidents during the survey.

Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to inform residents of their right to formulate advanced directives. This was found evident of 2 (Resident #160 & #121) out of 10 residents reviewed for advanced directives during the survey.

Inspectors wroteBased on complaint, resident medical record reviews, interviews with staff, and a review of the facility's policies and procedures, it was determined that the facility failed to immediately permit 1 (Resident #165) of 3 residents investigated for discharge, to return to the facility after a therapeutic service and a visit to the emergency room. This resulted in the resident returning to the hospital's emergency department for an additional 8 days.

Inspectors wroteUpon record review and facility staff interviews it was determined that the facility failed to code resident medication accurately on the Minimum Data Set (MDS) assessment. This was true for 1(Resident #61) of 32 residents reviewed during the annual survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to develop a comprehensive person-centered care plan. This was found evident of 2 (Resident #5 & #160) of 5 residents reviewed for care planning.

Inspectors wroteBased on record review, and interview it was determined that the facility failed to invite a resident to participate in their care plan meeting and conduct care plan meetings after each resident's Minimum Data Set (MDS) assessment. This was found evident in 2 (Resident #134 & #90) out of 5 residents reviewed for care planning.

Inspectors wroteBased on resident clinical record review and facility staff interview, it was determined that the facility failed to develop and implement a discharge plan focused on the discharge goals for Resident # 166. This was evident for 1 (Resident #166) of 3 residents investigated for discharge during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent residents. This was found evident in 1 (Resident #134) out of 2 residents reviewed for Activity of Daily Living (ADL) cares.

Inspectors wroteBased on interviews, and record review, and facility policy, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 2 (Resident #108 & #5) out of 4 residents reviewed for respiratory care during the survey.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to ensure a resident received dialysis treatment as ordered by the provider. This was found to be evident for 1 (#183) of 2 residents reviewed for dialysis care during the annual survey.

Inspectors wroteBased on record review and interviews, it was determined that facility staff failed to appropriately document pro re nata (PRN) narcotic medication in the facility's medication administration record (MAR). This was found to be evident in 3 (Residents #4, #11, #53) of 3 residents reviewed for PRN medication administration during the recertification survey.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices. This was found evident in 2 records of (Resident #5 & #165) out of 70 residents reviewed during the survey.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility staff failed to maintain an infection prevention/control program i.e. standard of care of an enteral feeding tube. This was evident for 1 (Resident #17) out of 2 residents reviewed for feeding tubes during the annual survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This was found evident on 2 random observations on the Terrace level.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure that a resident's bed mattress properly fit the bed frame and that annual inspections were performed. This was found evident of 1 Resident (Resident #108) out of 160 beds.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to keep a sanitary environment in the common hallway. This was found in one random observation on the East Wing.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to have an effective pest control program. This was found evident on 2 observations (Resident 121's room and the elevator) and during one of three observations during kitchen tours on the annual survey.

Inspectors wroteBased on observation, interview of facility staff, and documentation review, it was determined that food service employees failed to ensure that sanitary practices were followed such as keeping equipment in the kitchen maintained, keeping a sanitary environment, and reporting when dishwasher final rinse temperatures were out of range. This was evident during the initial and follow-up tours of the facility kitchen during a complaint survey.

Inspectors wroteBased on complaint # MD00189766, observation, and interviews, the facility failed to keep the facility in good repair. This was evident in all rooms and hallways in the facility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#82, #79, #89, #76) of 96 residents reviewed during a complaint survey.

Inspectors wrote4) Review of the medical record for Resident #21 on 10/19/23 revealed multiple comorbidities including hypertension, stroke with hemiplegia on his/her dominant side and seizures. Resident #21's hospital discharge record from 11/2020 included recommendations for a follow up with a cardiologist secondary to the finding of a cardiac aneurysm and follow up with a neurologist. Resident #21 was interviewed on 10/23/23 at 9:54 AM. Surveyor inquired about his/her discharge process and any follow up appointments that s/he was given or told to make. S/he stated that they were unaware of any. Surveyor reviewed the discharge summary completed on 3/2/21, under section M. scheduled appointments and tests it stated, follow up with your primary doctor in 2 weeks. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to ensure that resident's medications were administered as ordered. This was evident for 4 (# 63, #72, #70, #33) of 96 resident reviewed during a complaint survey.

Inspectors wroteBased on medical record review, interview, and observation, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 8 (#69 #42, #55, #22, #46, #4, #17, #47) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on observations during an environmental tour and interviews, it was determined that the facility failed to maintain a safe, sanitary, comfortable, and functional environment for the residents, staff, and visitors.

Inspectors wroteBased on medical record review and interviews, it was determined the facility staff failed to include a resident's Power of Attorney representative in the care of a resident (Resident #50). This was evident for 1 of 19 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to ensure call bells are within reach and failed to ensure a bariatric bed was available for a resident. This was evident for 2 (#12, #35) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to notify a resident's representative (RP) in a timely manner of a resident's death (Resident #5). This was evident for 1 of 3 residents reviewed for notification of death during a complaint survey.

Inspectors wroteBased on review of complaints and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) for Resident #89 and failed to report abuse for Resident #94. This was evident for 2 of 21 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on review of facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse. This was evident for 1 (#85, #39, #94) of 21 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on complaint review, medical record review, and interview, it was determined that the facility staff failed to create and implement care plans related to resident's specific needs. This was evident for 4 (#79, #55, #76, #61) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan and failed to evaluate and update a resident's care plan. This was evident for 4 (#83, #86, #65, #22) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint # MD00169194, Medical Record Review of MDS, and GNA [NAME], the facility failed to toilet residents on a regular basis. This was evident for 1 (Resident #4) of 1 resident reviewed for toileting.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to assess, document, and treat a surgical site and failed to ensure that the facility staff were able to administer a medication before admitting a resident to the facility. This was evident for 2 (#46, #60) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint review, medical record review, and interview, it was determined the facility failed to ensure a resident continued to have access to a retinal specialist and/or ophthalmologist for follow-up for a retinal problem. This was evident for 1 (#55) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interviews it was determined the facility staff failed to provide appropriate treatment and services to promote healing of pressure ulcers. This was evident for 3 (#82,#76, #58) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, interview with facility staff and the review of a complaint, it was determined that the facility failed to adequately investigate the cause of an alleged fall and thereby prevent further occurrences. This was evident during the review of 1 of (3) falls reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to provide adequate management of a resident's pain medication (resident #36) resulting in the resident being denied pain medication when they requested it.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to obtain post dialysis treatment records for Resident #18. This is evident for 1 out of 3 residents reviewed for dialysis services during a complaint survey.

Inspectors wroteBased on review of complaint MD00187110, facility documentation, medical record review and interview, it was determined that the facility failed to have sufficient nursing staff to provide care in a manner to provide nursing care needs to residents. This was evident for 2 of 2 days reviewed for sufficient staff during a complaint survey.

Inspectors wroteBased on review of complaint, interview, and documentation review, it was determined the facility failed to have a process in place to assure resident transportation arrangements were made timely. This was evident for 1 (#68) of 19 residents reviewed during a complaint survey that were currently residing in the facility.

Inspectors wroteBased on review of complaint MD00197454, medical record review, and interview with facility staff, it was determined that the facility failed to ensure a resident received their prescribed diet with the prescribed consistency. This was evident for 1 (#89) of 96 residents reviewed during a complaint survey.

Inspectors wroteBased on observation during tour of the facility's dumpster area, it was determined the facility staff failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the consultant pharmacist failed to identify and/or ensure that the facility staff established perimeters for the continued use of anti-depression medication for Resident (#10). This was evident for 1 (R#10) out of 5 sampled residents reviewed for medication regimen review during the investigative portion of the survey process.

Inspectors wroteBased on staff observations of the facility's kitchen/ food services and staff interview, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was identified during an initial inspection of the facility's dish washing machine and dishwasher temperature logs. The proper dishwashing temperature was not maintained for 3 of 3 months of temperature logs reviewed.

Inspectors wroteBased on the review of the facilities infection control program, it was determined that the facility staff failed to ensure that a surveillance plan was established/ implemented in place. This was evident during the investigation of the facilities infection control program review during the survey process.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident to an acute care facility along with the reason for the transfer. This was evident for 3 (#15, #90, #81) of 5 residents reviewed for transfer to an acute care facility.

Inspectors wroteBased on resident and staff interview and medical record review it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident/exemplified for 6 (#127, #181, #52, #60, #90, #105) of 41 residents reviewed.

Inspectors wroteBased on medical record review, and staff interview it was determined that the facility failed to have an effective system in place to ensure that a care plan meeting was held after each resident assessment, failed to ensure that care plans were thoroughly evaluated and revised by the interdisciplinary team after each assessment, and failed to ensure the documentation of why the resident or responsible party was unable to attend a care plan meeting. This is exemplified for 7 residents (#46, #127, #15, #52, #7, #16 and #10).

Inspectors wroteBased on observation, resident and staff interview it was determined that facility staff failed to ensure that all residents were treated with respect and dignity by receiving permission from residents before entering resident's rooms. This was evident for 1 out of 10 residents who were interviewed involving (R#8) observed during the survey process.

Inspectors wroteBased on observation, interviews and medical record review it was determined that the facility staff failed to: 1) bathe a resident according to his/her preference, 2) to have a process in place to make meal choices available to those residents who ate in their room and wanted a different meal, and 3) to provide an escort for those individuals who need extensive assistance when out on an appointment. This was evident for 3 (#46, #35, #16) of 5 residents reviewed for Choices during the facility's annual Medicare/Medicaid Survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to obtain incapacity certifications and medical condition certifications prior to allowing a surrogate decision maker to withhold life sustaining treatments. This was evident for 1 (#124) of 1 resident reviewed for advanced directives.

Inspectors wroteBased on surveyor observation and staff interview it was determined the facility staff failed to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was evident throughout the survey and on multi-levels of the facility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2(#132) and (# 90) of 2 residents reviewed for MDS accuracy.

Inspectors wroteBased on record review, the facility failed to develop a baseline care plan for Resident #90 who had C-diff and went to dialysis 3 times per week. This was evident for 1 out of 1 residents that did not have a baseline care plan.

Inspectors wroteBased on medical record and staff interview, it was determined that the facility staff failed, 1) to perform a routine 2 hour turning and 2) failed to apply splint to left lower extremity for resident who had a contracture of left ankle. This was evident for 2 (#9, #7) out of 3 residents investigated for activities of daily living.

Inspectors wroteBased on resident and staff interview, the facility staff failed to follow up and treat Resident #60 for a change in bowel status. This was evident for 1 out of 41 residents investigated during the survey process.

Inspectors wroteBased on review of medical records and staff interviews, it was determined the facility staff failed to provide adequate supervision to ensure the safety of Residents #20 ,#71 and #117 , who smoke. This was evident for 3 out of 4 residents investigated while smoking during the survey process.

Inspectors wroteBased on observation and record review, the nursing department failed to review orders and administer the correct liters of oxygen according to Doctors orders provided for Resident # 105 who receives oxygen. This was evident for 1 out of 41 residents.

Inspectors wroteBased on the medical record review, it was determined that the facility staff failed to document an assessment of Resident #9 in a timely manner. This was evident for 1 out of 41 residents investigated during the survey process.

Inspectors wroteBased on observation and staff interviews it was determined that the facility staff failed to develop a care plan that is specific enough for Resident #55, with a diagnosis of dementia. This was evident for 1 out of 5 Residents reviewed for unnecessary medications.

Inspectors wroteBased on resident interview, observations, medical record review and staff interview it was determined that the facility failed to provide meals and food items that were high in fiber. This was evident for 1 (#181) of 2 residents reviewed for nutrition.

Inspectors wroteBased on medical record review and staff interviews it was determined that the facility failed to have medical records readily available. This was evident with all medical records reviewed for multiple days of the survey. Additionally, the facility failed to carry over physician orders (4) for Resident # 26, Resident # 105, Resident 127 and Resident 181. This is evident for 2 out of 41 residents reviewed during the survey.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to equip corridors with firmly secured handrails. This was evident on 1 of 3 nursing units observed.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. It was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for 8 out of 8 days of the survey.