Adelphi Nursing: Medication Record Error Flagged - MD
The error involved tranexamic acid, a drug used to control bleeding. When Resident #2 arrived at the facility from a hospital, a nurse transcribed a one-time dose of tranexamic acid onto the resident's medication administration record. The order did not belong to Resident #2. It belonged to someone else entirely. The hospital's discharge paperwork had mixed up the records, and the nurse transferred the order without checking whose name was on the document.
The Director of Nursing, interviewed on October 16, was direct about what she expected her staff to do. When a resident arrives from a hospital, she said, nurses are supposed to review the transfer summary and confirm that the name on the paperwork matches the resident receiving the orders. That check did not happen here.
The Administrator, in a follow-up interview four days later on October 20, described it the same way: a transcription error, caused by a nurse who did not verify the name before entering the order into the record.
Federal inspectors cited the facility under F0842, which covers the accuracy and completeness of medical records. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting a few residents.
The citation reflects something that happens at the precise moment a nursing home is supposed to be most careful: admission. A resident arrives from a hospital, often with complex medical needs, carrying paperwork that staff must interpret quickly. That transition is where errors migrate from one setting to another. In this case, a medication order written for a different patient crossed over and attached itself to someone who had no reason to receive it.
The facility's own leadership did not dispute what happened. The Director of Nursing acknowledged the name check was expected. The Administrator confirmed the name was not checked. What neither said was how long the order sat on Resident #2's medication record before anyone noticed, or whether the resident received the drug.
The inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adelphi Nursing and Rehabilitation Center from 2025-10-20 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 8, 2026 · Our methodology
ADELPHI NURSING AND REHABILITATION CENTER in ADELPHI, MD was cited for violations during a health inspection on October 20, 2025.
The error involved tranexamic acid, a drug used to control bleeding.
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.