Federal inspectors found that Adelphi Nursing and Rehabilitation Center failed to create protocols for tracking the pacemaker of Resident #16, who was admitted in August with atrial fibrillation, heart failure, and severe cognitive impairment.
The resident scored just 6 points on a mental status assessment, indicating severe cognitive problems that would prevent them from monitoring their own cardiac device. Their admission record documented multiple serious heart conditions including atrial fibrillation, congestive heart failure, severe tricuspid regurgitation, hypotension, and cardiomyopathy.
Despite these complex cardiac issues requiring a pacemaker, the facility's care plan contained no instructions for staff on how to monitor the device's proper functioning.
The nursing home's own policy, effective since November 2019, requires licensed nurses to develop individualized care plans that provide "effective, person-centered care" and "necessary health-related care and services." The policy specifically states that care plans should help residents "attain or maintain the highest practical physical, mental, and psychosocial well-being."
Resident #16's care plan, created on August 19 and revised on September 10, acknowledged they were "at risk for cardiac complications" due to their multiple heart conditions. But the plan contained no section addressing the pacemaker or directing staff how to ensure it was working properly.
The oversight persisted for two months. Only on October 16 did the facility issue an order stating "FYI: Resident has pacemaker device, every shift" — a basic notification rather than monitoring protocols.
When inspectors interviewed the resident on October 16, they confirmed they had a pacemaker. Four days later, the facility's Director of Nursing acknowledged to inspectors that the resident's pacemaker "should be addressed on their care plan."
The admission occurred on August 11. The care plan was first created eight days later, then revised nearly a month after that. Neither version included pacemaker monitoring despite the resident's documented cardiac history requiring the device.
Pacemakers regulate heart rhythms in patients with conditions like atrial fibrillation, where the heart's electrical system malfunctions. For residents with severe cognitive impairment, nursing staff become responsible for monitoring signs that the device is working properly, including checking pulse rates and watching for symptoms of device failure.
The facility's care plan did acknowledge the resident's cardiac risks, listing their atrial fibrillation, congestive heart failure, severe tricuspid regurgitation, hypotension, and cardiomyopathy. But it provided no guidance for the one intervention keeping those conditions stable — the pacemaker.
The October order requiring staff to note the pacemaker "every shift" came more than two months after admission, and only after the facility had already revised the care plan once in September.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the gap left a cognitively impaired resident dependent on others to monitor a device critical to their survival.
The inspection occurred following a complaint. Inspectors reviewed four residents with pacemakers and found the care planning failure affected one of them.
Resident #16 remains at the facility with multiple heart conditions requiring the pacemaker their care team failed to properly plan for monitoring. The device that regulates their heart rhythm went unaddressed in care plans for more than two months, despite facility policies requiring individualized protocols for each resident's medical needs.
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.
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