Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allendale Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
The facility failed to follow professional standards and its own policies for pressure ulcer prevention, treatment, and skin assessment for three residents. One resident with recent brain surgery, debility, incontinence, and malnutrition risk had a sacral pressure injury that was not accurately identified on readmission, was not promptly treated when first noted as an open area, and was allowed to progress from an undocumented early stage to stage IV with exposed bone, without consistent care plan updates, family notification, or documented response to worsening labs and repeated debridements. Another resident with existing pressure injuries and osteomyelitis received overlapping and conflicting wound treatments after a nurse, believing there was no order, obtained an additional daily dressing order that remained active for several days, contrary to the wound clinic’s 3x/week dressing order and without documented rationale. A third resident at high risk for skin breakdown, with Parkinson’s disease and protein-calorie malnutrition, did not receive ordered weekly skin assessments, with gaps of 10 to 18 days and no documentation explaining the missed or late assessments.
Failure to follow ordered meal safety precautions led to one resident with stroke-related weakness and aspiration risk eating meals without 1:1 supervision, then choking and vomiting during medication administration after the meal. A second resident with Parkinson's disease was observed drinking hot coffee from an uncovered cup and without a clothing protector despite care plan instructions for a lidded cup and clothing protector.
Food storage and sanitation practices were not maintained in the kitchen and serving areas. Staff observed multiple unlabeled and undated foods, including leftovers, opened packages, and expired items in coolers, freezers, and a dining room refrigerator; food debris was also seen on equipment, tables, and in the microwave. The FSD stated there were no cooling logs for leftover foods and that the facility did not implement cooling procedures. Warewashing area surfaces had absorbent foam caulking and gaps that could not be easily cleaned, and double-walled water cups retained condensation after dishwasher use.
A resident with orthostatic hypotension received Midodrine outside ordered BP hold parameters on multiple occasions, with the eMAR showing doses given when systolic BP exceeded the prescribed limits. In a separate event, an RN failed to verify narcotic quantity and did not document two Morphine Sulfate dose removals on the Controlled Substances Proof of Use form during a shift change count, contrary to the facility’s narcotic sign-out policy.
Unlocked medication carts and improper storage of a medication pass supplement were observed. A cart on the 200 hall was left unattended with an opened, undated glargine insulin pen for a resident and loose unidentified pills in a drawer. Two 100 hall med carts were also found unlocked, and an RN left a cart unlocked while administering an PRN narcotic. An open container of a medication pass supplement was also found in the med refrigerator.
Infection control practices were not followed for two residents requiring EBP and one resident using a wheelchair with damaged armrests. An LPN provided wound care without a gown, CNAs entered rooms without the required gown for high-contact care, and one CNA did not perform hand hygiene or change gloves appropriately during bathing and incontinence care. Another resident was observed in a wheelchair with torn arm coverings exposing a surface that was not cleanable.
Facility Cleanliness and Repair Deficiencies: Surveyors observed a bag of soiled linens on the floor and fecal matter on a shower chair and leg in a spa shower room. They also observed damaged janitor closet shelving with peeling laminate, swelling particleboard, and a mold-like growth, a mop sink with a gap that allowed water to splash out and run onto the floor, and shower rooms with peeling, chipping, and stripping paint on tiled surfaces. The MD stated he was unaware of the shelving damage and that shower room renovation work was in the beginning work order process.
A resident whose preferred language was Castilian Spanish was unable to communicate effectively with staff. She could not speak English, had difficulty using a handheld device for translation, and staff reported limited options beyond an interpreter phone or family contact. The resident said staff were not always able to understand her needs, including laundry and pain, and the care plan did not include a specific approach for her primary language.
Failure to provide routine hand hygiene for two dependent residents was observed. One resident with stroke-related weakness and paralysis had a thick brownish substance under the fingernails on two observations, and another resident with stroke-related weakness and paralysis had a dark substance coating the fingernails and stated staff did not clean his hands before meals.
A resident with stroke-related right-sided weakness and paralysis, who required two staff for bed mobility, was observed sliding down in bed when an LPN raised the HOB for meds and was left without having her position checked. Her feet were repeatedly observed pressed against the footboard, and she stated she could not move her legs and feet and that her feet hurt in that position.
Missing Pharmacist MRR Record: The facility failed to receive, act upon, and maintain a pharmacy report after a pharmacist MRR for a resident with multiple diagnoses including DM2, bipolar disorder, A-fib, COPD, seizure disorder, HTN, weakness, and anemia. The pharmacist's review noted a requested action, but the actual report could not be located in the EMR or resident record, and the ADON stated the facility did not know what medication the pharmacist wanted addressed.
Failure to monitor antibiotic use and review antibiotic orders led to two residents receiving antibiotics without clear indication. One resident with dementia and chronic kidney disease was given antibiotics for a presumed UTI despite no documented urinary symptoms and no fever on the temperature log, while another resident returned from the ER on cefuroxime for a UTI even though the culture later showed no bacterial growth. The DON and ICP stated the records did not support the antibiotic use as documented.
The facility failed to properly administer and document controlled substances for four residents, leading to medication errors and discrepancies in records. A resident did not receive a scheduled dose of Norco, while another received an additional dose of Belsomra without proper documentation. Discrepancies were also noted in the administration records of clonazepam and oxycodone for two residents.
A facility failed to maintain the 100-hall medication refrigerator within the safe temperature range, potentially rendering medications ineffective. The refrigerator was overfilled, lacked shelves, and had a thermometer reading of 32°F, below the required 36-46°F range. Medications for nine residents, including insulin and Trulicity, were stored improperly, risking their effectiveness.
A resident with expressive aphasia experienced frustration and isolation due to the facility's failure to provide adequate communication tools. Despite being cognitively intact, the resident's communication needs were not met, as staff did not utilize the provided communication binder or iPad for communication. The resident was not involved in care conferences, and his communication needs were not addressed, leading to ongoing frustration and inability to express his needs effectively.
The facility failed to properly assess and manage pain and wound care for three residents. One resident's severe pain was not adequately addressed, with pain assessments often recorded as zero despite high pain levels. Another resident experienced issues with wound care due to a lack of supplies and incorrect dressing application. A third resident's antibiotic treatment for a UTI lacked follow-up culture results to confirm its appropriateness.
A facility failed to follow its hospice care policies, resulting in inadequate communication and coordination for a resident receiving hospice services. The resident, with diagnoses including hospice and dementia, reported chronic pain and insufficient toenail care. Interviews revealed missing hospice documentation in the EMR, and staff acknowledged the lack of necessary information from the hospice agency, leading to the deficiency.
A resident's BiPap machine was not cleaned as required, despite records indicating otherwise. The resident, with multiple health conditions, reported the lack of cleaning since admission. The DON confirmed the absence of cleaning and uncertainty about who marked the tasks as completed on the MAR, indicating a failure in the facility's infection control program.
The facility failed to ensure controlled substances were accurately accounted for, as evidenced by missing nursing signatures and incomplete documentation on narcotic logs and emergency controlled substance inventory sheets. The Director of Nursing was unaware of these issues until the survey.
The facility failed to manage food safety and sanitation, risking foodborne illness for 51 residents. Observations showed missing paper towels at the handwashing sink, staff not washing hands, and improper equipment monitoring. Logs revealed inconsistent monitoring of dish machine and refrigerator temperatures. Improper food storage and unclean equipment were also noted, violating FDA Food Code standards.
The facility failed to provide a clean and safe environment for residents, with issues including damp washcloths with a brown substance in a resident's room, fecal matter in the spa room shower area for three days, leftover food trays in the dining room, and an unsecured light in an unlocked mechanical room.
The facility failed to ensure timely medication administration and proper glucose monitoring for several residents, resulting in missed doses and unaddressed elevated blood sugars. An agency nurse's late arrival and unfamiliarity with the system contributed to the delays. Additionally, a resident with a UTI did not receive the prescribed antibiotic treatment due to refusal and transcription errors, highlighting deficiencies in medication management and quality care.
The facility failed to implement fall prevention measures for four residents with dementia and other conditions, leading to deficiencies in accident prevention. Observations revealed that call lights were often out of reach or sight, contrary to care plan instructions. A CNA confirmed that staff were expected to check call light placement, indicating a failure to adhere to this protocol.
A resident with dementia and other health issues did not have access to water as per their care plan, which required fluids to be available at the bedside and during activities. Observations showed the resident without water in the dining room, despite instructions for staff to ensure water was present. The DON acknowledged the need for staff education and suggested a cup holder for the resident's wheelchair to improve access to hydration.
A facility failed to ensure proper positioning and storage of tube feeding supplies for a resident. The resident's feeding supplies were improperly stored in a shared bathroom, and the bedside table was not cleaned before use. The resident was also observed lying flat during tube feeding, contrary to the required 30-degree head elevation. The facility's policies and care plan lacked guidance on proper positioning during continuous feedings.
Failure to Provide Standard Pressure Ulcer Prevention, Treatment, and Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury prevention and management in accordance with professional standards and facility policy for three residents, including failure to assess, care plan, treat, and communicate about pressure injuries and skin integrity. For one resident with a history of craniotomy, debility, incontinence, and malnutrition risk, the facility did not accurately identify or document a sacral/buttock pressure injury on readmission, did not notify the resident’s spouse or provider of a newly identified stage 1 pressure area, and did not update the care plan to include bowel incontinence or specific pressure-relief interventions. Subsequent skin assessments and physician notes did not reference a buttock wound, despite a Braden score indicating high risk and documentation that the resident was dependent on staff for repositioning. When an open area to the buttock was later identified and an alternating pressure mattress ordered, there was no documented notification to the spouse or provider and no immediate treatment order; the first documented wound treatment was initiated approximately 24 hours after the wound was identified. As the wound progressed, the facility did not consistently update the care plan or notify the resident’s spouse of changes in wound status, debridement procedures, or treatment changes. A wound consultant documented progression from a stage 2 to stage 3 and then to a stage 4 sacral pressure injury with increasing size and depth, requiring mechanical and sharp debridements and changes in topical therapy (Triad, Medihoney, then Dakin’s solution). The EMR lacked documentation of family notification for these changes, and the care plan was not revised to reflect the worsening wound, new diagnosis of pneumonia, or additional interventions to promote healing. Laboratory results showed declining albumin and protein levels and elevated WBCs, but there was no documentation of new interventions in response to these abnormal labs at the time they were reviewed. The wound treatment with Dakin’s solution was implemented more frequently than ordered for a period, without documentation of clarification with the wound provider. The resident later reported that ordered q2h turning was not being done, and hospital records described a large stage IV sacral ulcer with exposed bone and presumed osteomyelitis; the death certificate listed a stage 4 sacral ulcer due to malnutrition, with malnutrition related to dysphagia and a benign meningioma. For a second resident with existing pressure injuries and osteomyelitis, the facility did not follow the wound clinic’s order for a silicone bordered dressing to the right buttock three times weekly. Instead, concurrent and conflicting treatment orders were in place: zinc cream after each incontinence episode, a three-times-weekly dressing change, and an additional daily border gauze dressing ordered by the facility provider after a nurse erroneously believed there was no existing order. These overlapping orders resulted in wound care being performed more frequently than ordered by the wound clinic, and the EMR contained no documentation explaining the rationale for the additional treatment order. For a third resident with Parkinson’s disease, protein-calorie malnutrition, muscle weakness, and documented risk for impaired skin integrity, the facility failed to complete weekly skin assessments as ordered and as outlined in the care plan. Skin assessments were missed or delayed by 10 to 18 days, and there was no documentation in the EMR explaining the missed or late assessments. The Regional Nurse Consultant confirmed that weekly skin assessments were required by policy and that CNA shower sheets were not to replace licensed nurse skin assessments, yet these assessments were not completed as directed.
Failure to Follow Ordered Meal Safety Precautions
Penalty
Summary
The facility failed to implement ordered safety precautions for two residents reviewed for accidents. One resident had a recent stroke with right-sided facial, arm, and leg weakness and paralysis, depended on staff for all daily needs, and had a speech therapy recommendation for 1:1 staff assistance during all meals because of reduced oral motor skills and signs of aspiration. A therapy communication form also directed 1:1 feeding assistance due to intermittent physical assistance needs, aspiration risk, and decreased sensation on the right side of the face. Despite these directions, the resident was observed eating breakfast and lunch in bed without staff supervision, and the call light was out of reach and out of sight during lunch. During the lunch meal, staff removed the tray only after realizing the resident was unsupervised. The resident reported chest pain, and an LPN acknowledged the complaint but stated it was "pretty normal" for the resident. The resident later cried, appeared anxious and red in the face, and could not tolerate vital sign attempts. When medications crushed in pudding were administered, the resident began choking and coughing and vomited unchewed food from the meal. The LPN stated the resident had aspirated and would need a chest x-ray, and the resident was later found to have abnormal lung sounds and was sent to the emergency department. A second resident with Parkinson's disease, cognitive communication deficit, and muscle weakness was observed eating breakfast with hot coffee in an uncovered cup and without a clothing protector, despite meal ticket instructions and a quarterly hot food/liquid assessment directing a lidded cup and clothing protector.
Food Storage and Sanitation Deficiencies in Kitchen and Serving Areas
Penalty
Summary
The facility failed to maintain sanitary food storage, labeling, dating, and handling practices in the kitchen and dining room serving areas. During observation, the kitchen door was open from the dining room with no staff present, hair nets were not available at the kitchen entrance, and dirty dishes and food scraps were seen on a cart and on a dining room table outside the kitchen. In the kitchen, the microwave contained dried food debris on the inside and door, and multiple food items were observed without labels or dates, including an unknown soup in a 4-quart container, a wrapped turkey sandwich, opened lunch meat, opened pepperoni, opened dry cereal bags, and a pan of pasta with red sauce that had been served previously and left over from an earlier meal. Additional food storage concerns were observed in the reach-in cooler and freezer. A large bag of iceberg lettuce was open to air, a container of sour cream had expired, frozen ground beef patties were open to air in an unclosed plastic bag, and a tray of fruit cups in the main dining room refrigerator was uncovered and without a label or date. Applesauce portioned into plastic containers also lacked labels or dates, and a plastic grocery bag containing unknown food was stored in a refrigerator that had a sign stating no resident or staff food or drinks were to be stored there. The Food Service Director stated the minestrone soup was from the week before, said there were no cooling logs for the soup or the pasta, and reported that the facility does not implement cooling procedures. The report also documented sanitation and equipment concerns in the kitchen and warewashing area. Foam caulking at the dirty side of the dishwasher table was spongy and absorbent, and the clean side had gaps in caulking that could not be easily cleaned. Food debris, crumbs, dried greens, and a twist tie were observed behind items on the baker's table, and crumbs were seen in the dry basin of the steam well. In addition, double-walled water pass cups washed in the dishwasher retained condensation between the walls after washing, and the manufacturer’s site indicated the cups were not intended for washing in a commercial dishwasher and were rated only for top-rack washing.
Medication Parameters and Narcotic Accounting Failures
Penalty
Summary
The facility failed to follow physician-ordered medication parameters for a resident with orthostatic hypotension, diabetes, high blood pressure, muscle weakness, and lack of coordination. The resident was ordered Midodrine 10 mg three times daily with instructions to hold the medication when the systolic blood pressure was greater than 120, and later greater than 130. Review of the eMAR showed multiple administrations of Midodrine when the resident’s systolic blood pressure was above the ordered hold parameters, including readings of 128, 134, 136, 138, 140, 145, 147, 150, 152, 157, and 161 at the times the medication was given. The facility also failed to follow professional standards and its narcotic accounting policy for another resident receiving Morphine Sulfate solution 5 mg every 3 hours as needed. During a shift change narcotic count, an RN was observed documenting removal of two doses, and stated that when she pulled a dose at midnight and again at 6:00 AM, she did not verify the quantity in the container or document the removal on the Controlled Substances Proof of Use form as required. The form stated that every dose must be accounted for and that doses that are contaminated, lost, broken, or refused must be entered under comments, and the facility policy directed staff to sign out narcotics when removed from the narcotic box and after administration.
Unlocked Medication Carts and Improper Storage of Supplement
Penalty
Summary
The facility failed to secure three of four medication carts and properly store a medication pass supplement. During an observation on 02/09/26 at 8:47 AM, the 200-hall low side medication cart was left unlocked and unattended by nursing staff. Inside the cart, a glargine insulin pen for resident #42 was observed opened and not dated, and six loose unidentified pills were found in the bottom of the second drawer. RN B returned to the cart at 8:56 AM. During observations on 2/10/2026, the main 100 Hall medication cart and the split 100 Hall medication cart were both found unlocked and unattended by a licensed nurse. RN J stated during interview that she was responsible for both carts and knew they should have been locked when unattended. Later that morning, RN J prepared an as needed narcotic medication for a resident, closed the cart drawer, and left the cart unlocked while going to the resident room to administer the medication. In the medication storage room, RN J unlocked the medication refrigerator and an open container of a medication pass supplement was observed on the top shelf. The facility policy stated cart security is maintained during the entire med pass and that opened food/juice must be covered and dated when placed in a refrigerator, used within 48 hours or per manufacturer recommendation, and stored in a separate refrigerator from medications.
Infection Control Lapses During EBP Care and Use of Non-Cleanable Wheelchair
Penalty
Summary
The facility failed to implement infection prevention and control practices for residents requiring Enhanced Barrier Precautions (EBP). Resident R13 was admitted with pressure ulcers, and during wound care an LPN was observed providing dressing changes without a gown despite a posted EBP sign outside the room. After the dressing change, a CNA entered the room without a gown to assist with incontinence care. The LPN stated he should have worn a gown for wound care and that the CNA should have used the appropriate PPE as well. Resident R27, who had a history of stroke and was cognitively intact, required supervision and touching assistance for toileting hygiene and bathing. During a bed bath, a CNA entered the room without a gown despite the EBP sign, donned gloves, and performed incontinence care and bathing tasks. The CNA did not change gloves or perform hand hygiene at several points while moving between contaminated and clean tasks, including after perineal care, before handling the nasal cannula and shirt, before touching the shower cap and hair, and while handling personal items and bed controls. Resident R20 was observed sitting in a wheelchair with torn and tattered vinyl on the armrests exposing underlying fabric that was not cleanable.
Facility Cleanliness and Repair Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the facility. On 02/09/26 at 12:40 PM, in the spa shower room across from room [ROOM NUMBER], surveyors observed a bag of soiled linens on the floor, fecal matter smeared on a blue shower chair, and fecal matter on one of the shower chair legs. On 02/10/2026 at 2:25 PM, particle board shelving in the janitor closet next to the housekeeping office was observed with peeling laminate, swelling of the particleboard, and a mold-like growth on the exposed particleboard; the Maintenance Director stated he was unaware of the shelving damage. On 02/10/2026 at 2:26 PM, the mop sink was observed with a large gap between the sink and the wall, allowing water to splash out and run down the wall and accumulate on the floor. On 02/10/2026 at 3:00 PM, the shower room on 100 hall had peeling and chipping paint on tiles, and the Maintenance Director stated the facility was in the beginning work order process of renovating the shower room to include removal and replacement of tile. On 02/10/2026 at 3:15 PM, the shower room on the west hallway was observed with paint peeling in strips from the painted tiling in the shower area.
Failure to Provide Effective Communication for a Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide an effective way to communicate for a resident whose preferred language was Castilian Spanish. The resident was observed lying in bed receiving IV therapy and responded in a different language when asked questions. She indicated through gestures that she could not speak English and attempted to use a handheld device from her drawer, but the device required a Wi-Fi connection and she did not know how to use it at that time. During interviews, an LPN reported the resident was fluent in Spanish and only spoke a little English, while a CNA reported the resident could gesture for a pain pill but had no other way to communicate basic needs and was not aware of any communication boards. The resident reported that staff were not always able to communicate with her and gave an example of laundry in her closet that needed to be cleaned but that she was unable to tell staff. She also stated that a communication board for needs such as toileting, pain, and laundry would be helpful. Review of the care plan showed only an intervention for staff to repeat or reword conversations to help the resident understand and follow conversations, with a possible language barrier noted, but no other care plan problem or approach addressing her primary language of Spanish. The DON stated the facility had an interpreter service phone number and the resident had a phone in her room, but was not aware of any communication board for simple needs or a pain scale.
Failure to Provide Routine Hand Hygiene
Penalty
Summary
The facility failed to provide routine hand hygiene for two dependent residents who were unable to perform their own personal care. Resident #43, a female with a recent stroke causing right-sided facial, arm, and leg weakness and paralysis and difficulty speaking, was dependent on staff for all hygiene and activities of daily living. During observations on 02/09/26 and 02/10/26, her fingernails were noted to have a thick brownish substance under them. Resident #2, a male with a stroke causing difficulty speaking and right-sided weakness and paralysis, also depended on staff for personal care and hygiene. During an observation on 02/11/26, a dark substance coated his fingernails, and when asked whether staff cleaned his hands prior to each meal, he responded no.
Improper Bed Positioning and Footboard Contact
Penalty
Summary
The facility failed to ensure safe and proper positioning was maintained for a resident with a history of stroke causing right-sided facial, arm, and leg weakness and paralysis, who required assistance from two staff persons to move and reposition in bed. During an observation, an LPN raised the head of the bed to administer medications, and the resident slid down in the bed when the head of the bed was raised; the LPN did not check the resident's position before leaving the room. The resident's feet were observed pressed against the footboard during the same observation, and the resident stated she could not move her legs and feet and that her feet hurt when pushed up against the footboard. On a later observation, the resident was again found lying in bed with the head of the bed elevated, with one foot pressed against the footboard and the black electrical cord for the mattress lying between the footboard and the resident's other foot; the resident again stated her feet hurt in that position.
Missing Pharmacist MRR Record
Penalty
Summary
The facility failed to ensure it received, acted upon, and maintained a record of a pharmacy report after a pharmacist Medication Regimen Review for one resident. The resident was admitted with diagnoses including type 2 diabetes, bipolar disorder, atrial fibrillation, COPD, seizure disorder, high blood pressure, weakness, and anemia. Review of a pharmacist Drug Regimen Review dated 1/20/2026 showed the pharmacist made recommendations and noted, "Please take the following action described below," with the space for the requested action stating, "See report." However, the report itself could not be located in the resident's record. Review of the EMR Documents tab did not reveal any pharmacy records for the resident. During interview on 2/11/2026 at 3:46 PM, the ADON stated the pharmacy report/review could not be located and the facility did not know what medication the pharmacist requested action on. The facility policy on Medication Regimen Review stated the consultant pharmacist would provide MRRs to identified personnel, who would ensure the attending physician, medical director, DON, and other necessary staff receive the recommendations, and that the facility should maintain readily available copies of consultant pharmacist reports on file in the facility and as part of the resident's permanent health record.
Failure to Monitor Antibiotic Use and Review Antibiotic Orders
Penalty
Summary
The facility failed to implement its antibiotic use protocols for two residents reviewed for antibiotic stewardship. One resident with vascular dementia and chronic kidney disease was sent to the hospital for eye redness and cough with phlegm and returned with an order for Keflex for a urinary tract infection and antibiotic ointment for the eyes. The facility provider then changed the antibiotic order to doxycycline 100 mg twice daily for 5 days. Review of the resident’s progress notes from 10/01/2025 through 10/06/2025 did not reflect signs or symptoms of a urinary tract infection, and the hospital record documented that the resident denied urinary symptoms. Although the urine culture later showed greater than 100,000 CFU/mL Enterococcus faecalis, the record stated that a positive urine culture alone is not indicative of infection and that urinary symptoms are required for diagnosis and treatment of a UTI unless the patient is pregnant or undergoing urologic procedures. The DON stated the resident met McGeer’s Criteria based on fever and urgency/frequency, but the temperature log did not show a fever and the DON could not explain how fever was determined or why the antibiotic was discontinued three days after initiation. A second resident with a history of UTI and stroke with right-sided weakness and paralysis was sent to the emergency room and treated for a UTI with a culture and sensitivity pending. The resident returned with an order for cefuroxime 500 mg twice daily for 5 days and received the first dose on 01/29/26. The lab report dated 01/29/26 showed no bacterial growth on the culture. The Infection Control Preventionist stated that if the completed culture and sensitivity had been obtained and reviewed by the facility on 01/29/26, the antibiotic would have been discontinued because there was no indication for its use. The facility policy for the Antibiotic Stewardship Program required monitoring antibiotic use, monitoring responses and laboratory results to determine whether the antibiotic remained indicated, and reviewing antibiotic orders obtained from emergency providers for appropriateness.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to properly administer and document the administration of controlled substances for four residents, leading to medication errors and inaccurate documentation. For Resident #39, doses of oxycodone were administered on multiple occasions but were not documented in the Electronic Medical Record, which is crucial for ensuring adequate pain control and preventing narcotic diversion. Resident #25 did not receive an evening dose of Norco despite the medication being available, and there was no documentation or notification to the provider regarding the missed dose. Resident #50's clonazepam and oxycodone administrations were inconsistently documented between the Controlled Substances Proof of Use log and the Medication Administration Record, indicating discrepancies in medication administration records. Resident #24 received an additional dose of Belsomra, with unclear documentation regarding the timing and physician notification of the double dose. The Regional Clinical Director confirmed these errors, and the facility's policy requires immediate documentation of controlled substances removal and administration, which was not adhered to in these cases.
Medication Refrigerator Temperature Deficiency
Penalty
Summary
The facility failed to maintain the 100-hall medication refrigerator within the safe temperature storage range, which could potentially render medications ineffective. During an observation, the refrigerator was found to be overfilled with medications, lacking shelves, and the thermometer was buried among the medications. The freezer section had approximately one inch of ice buildup and was missing a freezer door. The thermometer, once located, indicated a temperature of 32 degrees Fahrenheit, which is below the required range of 36 to 46 degrees Fahrenheit. This discrepancy was reported to the Director of Nursing (DON) by the Licensed Practical Nurse (LPN) and the surveyor. The temperature log for the refrigerator showed that temperatures were recorded as 38 degrees Fahrenheit from January 1 to the date of the survey, with the morning temperature on the day of the survey marked as 39 degrees Fahrenheit. However, the actual temperature was found to be 32 degrees Fahrenheit. The refrigerator contained medications for nine residents, including insulin, Trulicity, and pain medications, all of which require storage within a specific temperature range to remain effective. The facility's failure to maintain the correct temperature and accurately log it could lead to the medications becoming ineffective, although the total number of vials, pens, or liquid amounts was not included in the inventory.
Failure to Provide Adequate Communication Tools for Resident with Aphasia
Penalty
Summary
The facility failed to ensure appropriate treatment and services to maintain communication for a resident with expressive aphasia, resulting in the resident feeling frustrated and isolated. The resident, a male with a history of stroke affecting his dominant right side and expressive aphasia, was admitted to the facility with a prior level of function that included using a communication board. However, the communication board was misplaced, and the resident required a new one. Despite being cognitively intact, the resident experienced a decrease in communication with caregivers and staff, leading to frustration and social isolation. Observations and interviews revealed that the resident was unable to effectively communicate his needs and desires due to the lack of appropriate communication tools. The communication binder provided was not within the resident's reach and was difficult to use with only his left hand. Staff did not utilize the communication binder or other tools, instead relying on yes or no questions to determine the resident's needs. The resident expressed frustration with this method and indicated a desire for an assessment into a new style of communication. The resident's care plan included the use of an iPad as a communication device, but it was not utilized for that purpose. The iPad was kept locked in the medication room and only used for watching movies. The resident was not invited to care conferences, and his communication needs were not addressed in these meetings. The facility's failure to provide appropriate communication tools and involve the resident in care planning contributed to the resident's ongoing frustration and inability to express his needs effectively.
Deficiencies in Pain Management and Wound Care
Penalty
Summary
The facility failed to assess and manage the pain and wound care of three residents, leading to deficiencies in their care. One resident, a male with end-stage renal disease and other conditions, reported severe pain that was not adequately assessed or managed by the nursing staff. Despite his complaints of pain reaching levels of 9 or 10 out of 10, the LPN did not ask him to rate his pain, and his pain assessments were often recorded as zero. Additionally, there was a lack of documentation and follow-up care after a podiatry appointment where a procedure was performed on his toe. Another resident, a female with lymphedema and rheumatoid arthritis, experienced issues with wound care. She reported that the dressing on her leg was not changed as ordered due to a lack of supplies, and the dressing that was applied did not contain the prescribed treatment. The DON confirmed these issues during an inspection and noted that the dressing was not dated or initialed as required. A third resident, a female, was admitted with a urinary tract infection and prescribed antibiotics. However, there was no documentation of culture results or confirmation that the prescribed antibiotics were appropriate for the infection. The Regional Clinical Director confirmed the absence of follow-up culture results, indicating a failure to ensure the correct antibiotic treatment was administered.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to implement and follow its policies and procedures for hospice care, resulting in a lack of communication and coordination of care for a resident receiving hospice services. The facility's policy requires a coordinated plan of care between the facility, hospice agency, and resident/family, which includes directives for managing pain and other symptoms. However, for one resident, there was no documentation of a hospice agreement, orders, communications, or visitations in the electronic medical records (EMR). The resident, who had diagnoses including hospice, cerebral infarction, and dementia, reported chronic pain and issues with toenail care, indicating a lack of comprehensive hospice service documentation and coordination. Interviews with facility staff, including the Regional Clinical Consultant, Licensed Practical Nurse, Social Worker, and Director of Nursing, revealed that hospice documentation was missing from the EMR and not available to front-line staff. The Social Worker and Director of Nursing were responsible for hospice coordination but had not ensured that necessary documentation was accessible. The Director of Nursing acknowledged that the facility did not have all the required information from the hospice agency, including the contract/agreement, visits, progress notes, and orders, and described the situation as a work in progress. This lack of documentation and coordination led to the deficiency identified by the surveyors.
Failure to Clean Resident's BiPap Machine
Penalty
Summary
The facility failed to properly clean a resident's BiPap machine, which is a breathing assistance device used during sleep. The resident, a male with multiple diagnoses including end-stage renal disease, diabetes mellitus with diabetic neuropathy, and cervical disc disorder myelopathy, reported that his BiPap equipment had not been cleaned since his admission. During an observation, the BiPap machine was found on the resident's nightstand with the mask still attached to the hose, and no cleaning supplies were present in the room. The Director of Nursing (DON) confirmed that there was no evidence of the BiPap machine being cleaned and was unsure who had marked the cleaning tasks as completed on the resident's Medication Administration Record (MAR). The MAR indicated that both weekly and daily cleaning tasks were marked as completed, despite the lack of actual cleaning. This discrepancy highlights a failure in the facility's infection prevention and control program, as the necessary cleaning procedures for the BiPap machine were not followed.
Deficiency in Controlled Substance Accountability
Penalty
Summary
The facility failed to operationalize its policies and procedures to ensure controlled substances were continuously and accurately accounted for between staff rotations. This deficiency involved all four controlled substance logs in the facility, leading to the potential for medication diversion. The facility's policy, titled Controlled Substances Standards of Practice, outlined procedures for accurately accounting for controlled substances through ordering, receiving, storage, administration, and destruction. However, a review of the August Narcotic Page Count Sheets for the 100-hall and 200-hall carts revealed several missing nursing signatures, incomplete information in the columns for adding or subtracting narcotics, and several entries missing resident information. Additionally, the August Emergency Controlled Substance Inventory Kit Verification log sheets on the medication carts showed several instances where nursing signatures were missing, failing to verify that the Emergency Controlled Substance storage was locked with a numbered tag. There were also instances where all three tags were changed with new numbers without another nurse's signature verifying or witnessing the change, and several days of documentation were missing. In an interview, the Director of Nursing acknowledged that the narcotic logs were incomplete and inaccurate and was unaware of the issue until the survey.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to properly manage food safety and sanitation practices, leading to an increased risk of foodborne illness for 51 residents. Observations revealed that the kitchen lacked essential items such as paper towels at the handwashing sink, and staff were seen not washing their hands before handling food. Additionally, the reach-in freezer did not have a thermometer, and the dish machine's water temperature did not meet the required minimum, indicating a failure in monitoring and maintaining equipment standards. Interviews and record reviews highlighted that the dietary manager was aware of lapses in monitoring the dish machine's chemical concentration and temperature, as well as refrigerator and freezer temperatures. Logs showed inconsistent monitoring of the dish machine and three-compartment sink sanitation, with missing records for several months. The facility also failed to implement a backup plan for dish sanitization when the dish machine was identified as not functioning properly. Further observations noted improper food storage practices, such as undated and uncovered food items in various refrigerators and freezers. The kitchen and storage areas contained equipment and surfaces that were not clean, with food residue and dirt accumulation. These deficiencies were in violation of the 2017 FDA Food Code, which mandates proper date marking, equipment cleanliness, and handwashing procedures to ensure food safety.
Deficiencies in Cleanliness and Safety in Resident Areas
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by several observations. In one instance, a bedside table in a resident's room contained two damp washcloths, one of which had a light brown substance on it, despite staff having been in the room earlier that morning to assist the resident. Additionally, the spa room shower area on the 100 hall was observed to have an almond-sized piece of fecal matter on three consecutive days, indicating a lack of timely cleaning. Furthermore, the small dining room off the kitchen had leftover dinner trays with partially finished food from the previous evening, accessible to residents the following morning. Lastly, an unlocked mechanical room housing the electrical service panel had an unsecured overhead fluorescent light leaning against the panel, posing a potential safety hazard.
Medication Administration and Quality Care Deficiencies
Penalty
Summary
The facility failed to ensure timely administration of medications and supplements, compatible administration times, and proper glucose monitoring for diabetic residents. This deficiency affected five residents, resulting in them not receiving their prescribed medications, supplements, and glucose monitoring as ordered by their physicians. For instance, one resident did not receive several medications, including insulin and nebulizer treatments, due to the unavailability of medications and the nurse's late arrival. The nurse, an agency staff member, was unfamiliar with the facility's electronic medical record system and the residents, which contributed to the delay in medication administration. Another resident with chronic kidney disease, diabetes, and other conditions did not receive multiple medications, including insulin and blood pressure medications, as ordered. The facility's Director of Nursing (DON) acknowledged that the pharmacy does not deliver over-the-counter medications, leading to delays in obtaining necessary medications. The DON also noted that agency nurses were not following up on ordering medications, resulting in residents not receiving their prescribed treatments. Additionally, the facility failed to provide quality care for a resident with a diagnosed urinary tract infection (UTI). The resident did not receive the prescribed antibiotic treatment due to refusal or unavailability of the medication. The facility's communication log indicated concerns about the resident's refusal of oral antibiotics and the potential risk of sepsis. However, the alternative antibiotic treatment ordered by the physician was not transcribed to the electronic medication administration record, and the resident did not receive the necessary treatment for the UTI.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention safety measures for four residents, leading to deficiencies in accident prevention and supervision. Resident #19, a female with dementia and repeated falls, was observed with her call light on the floor, tangled with bed controls, despite care plan instructions to keep it within reach and not leave her alone in a wheelchair. Resident #11, also with dementia and a history of falls, had her call light out of reach and sight, contrary to care plan interventions to change it to a soft touch call light and ensure it was accessible. Resident #3, a male with dementia and unsteadiness, was found with his call light on the floor, out of reach, despite care plan instructions to keep it within reach. Resident #20, a female with muscle weakness and epilepsy, had her call light clipped to a wall cord, making it inaccessible, despite care plan instructions to keep it within reach. A CNA confirmed that staff were expected to check call light placement each time they entered a resident's room, indicating a failure to adhere to this protocol.
Failure to Provide Hydration as Per Care Plan
Penalty
Summary
The facility failed to ensure that a resident had access to hydration according to their care plan. The resident, who had diagnoses including dementia, osteoporosis, repeated falls, and constipation, was identified as being at risk for impaired nutrition and hydration. The care plan included interventions such as encouraging fluid intake and ensuring fluids were available at the bedside and during activities. However, observations revealed that the resident did not have water available while seated in the dining room on multiple occasions, despite instructions for staff to place water with the resident. During interviews, the Director of Nursing acknowledged the oversight and noted that staff might need more education regarding the placement of the resident's water. The DON also suggested that a cup holder for the resident's wheelchair could facilitate easier access to water, especially when the resident was moving around the facility. This deficiency highlights a failure in executing the care plan's hydration interventions, potentially impacting the resident's health and well-being.
Improper Positioning and Storage of Tube Feeding Supplies
Penalty
Summary
The facility failed to ensure proper positioning and storage of tube feeding supplies for a resident with a feeding tube. During an observation, it was noted that the resident's bedside table was on the roommate's side of the room, and the plastic cylinder used for tube feeding was stored in the shared bathroom near the toilet. The LPN did not clean the table before placing medication cups on it and filled the plastic cylinder with water from the bathroom sink before administering medications and water to the resident through a syringe. Additionally, the resident was observed lying flat in bed while tube feeding was infusing, despite a sign indicating the head of the bed should be at a 30-degree angle. A CNA attempted to adjust the bed but did not have a tool to ensure the correct angle, resulting in the bed being at a 17-degree angle. The ADON confirmed the incorrect positioning and adjusted the bed. The facility's tube feeding policies did not address continuous enteral feedings or proper positioning, and the care plan for the resident did not include instructions for maintaining the head of the bed at the required angle during feedings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 417 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Allendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehab Center Of L | 2.7 mi | ★★★★★ | 10 | 0 |
| The Laurels Of Hudsonville | 7 mi | ★★★★★ | 1 | 0 |
| Valley View Care Center | 8.6 mi | ★★★★★ | 13 | 2 |
| Mission Point Nursing & Physical Rehabilitation Ce | 8.6 mi | ★★★★★ | 0 | 0 |
| Covenant Village Of The Great Lakes | 9 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.