Adelphi Nursing and Rehab: Fall Response Failure - MD
Together, a GNA and a member of the housekeeping staff lifted Resident 13 back into bed. That was the response. No charge nurse was notified. No clinical assessment followed, at least not in the way the facility's own administrator described as required.
The incident surfaced during a complaint inspection on October 20, 2025, when a federal surveyor interviewed the facility's administrator. The administrator confirmed what had happened and acknowledged that when an incident occurs, staff are supposed to notify the charge nurse. In this case, nobody did.
The violation was cited under F0684, which covers the standard of care residents are entitled to receive. Inspectors rated the harm level as minimal, or potential for actual harm, and noted that only a few residents were affected.
What the rating does not capture is what a fall without a clinical response actually means for an elderly person. A resident who has just fallen out of bed may have struck their head. They may have fractured a hip or wrist on the way down. Internal injuries do not announce themselves. The standard practice of notifying a nurse exists precisely because the person on the floor cannot always tell you what is wrong, and neither can a housekeeper.
The aide who responded to the fall, identified in inspection records only as GNA 14, made a decision in that moment to handle the situation without clinical oversight. Whether that decision came from a lack of training, a fear of reporting, a sense that the resident seemed fine, or something else entirely, the inspection report does not say. What it does say is that the charge nurse was never brought into the picture.
Housekeeping staff are not trained to assess fall injuries. They are not licensed to make clinical judgments about whether a resident who has just hit the floor is stable enough to be moved, or moved in a particular way. Lifting a person incorrectly after a fall can worsen a fracture or cause a spinal injury. The presence of a second set of hands does not substitute for a nurse.
The administrator, when asked about the incident during the October 20 interview, did not dispute what had happened. The account in the inspection report is matter-of-fact: the aide got help from the housekeeper, they got the resident back into bed, and the charge nurse was not told.
There is no indication in the report of what happened to Resident 13 afterward, whether they were later examined, whether they reported pain, or whether any injury was identified. The inspection report does not say.
Adelphi Nursing and Rehabilitation Center sits at 1801 Metzerott Road in Adelphi, a community in Prince George's County just outside Washington, D.C. The complaint inspection that produced this citation was completed October 20, 2025, and printed in final form the following April.
The facility was given the opportunity to submit a plan of correction. What changed for Resident 13 on the night of October 2 cannot be corrected.
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.
Together, a GNA and a member of the housekeeping staff lifted Resident 13 back into bed.
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.