Deficiency Records for Allendale Nursing and Rehabilitation Community
Updated as of March 01, 2024
A list of the most recent deficiencies for Allendale Nursing and Rehabilitation Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-06 | 2024-02-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-06 | 2024-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-06 | 2024-02-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-06 | 2024-02-08 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2023-12-06 | 2024-02-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-07 | 2024-01-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-07 | 2024-01-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-07 | 2024-01-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-07 | 2024-01-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-07 | 2024-01-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-07 | 2024-01-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-07 | 2024-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-01-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-07-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-09 | 2023-07-12 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-05-04 | 2023-05-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-04 | 2023-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-04-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-16 | 2023-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-01-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-30 | 2022-12-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-11-30 | 2022-12-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-30 | 2022-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2022-12-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2022-12-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-30 | 2022-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-30 | 2022-12-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-11-30 | 2022-12-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-30 | 2022-12-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-30 | 2022-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-30 | 2022-12-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-11-16 | 2022-12-26 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-16 | 2022-12-26 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-11-16 | 2022-12-26 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-16 | 2022-12-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-16 | 2022-12-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-16 | 2022-12-26 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-02 | 2022-12-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-02 | 2022-12-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-02 | 2022-12-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-02 | 2022-12-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-02 | 2022-12-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-02 | 2022-12-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-02 | 2022-12-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-25 | 2022-09-16 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-06-02 | 2022-07-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-02 | 2022-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-02 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-07-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-02 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-30 | 2021-12-29 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-09-17 | 2021-11-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-17 | 2021-11-10 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-09-17 | 2021-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-11-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-22 | 2021-11-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-22 | 2021-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-22 | 2021-11-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-22 | 2021-11-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-22 | 2021-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-22 | 2021-11-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-22 | 2021-11-10 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-09-22 | 2021-11-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-22 | 2021-11-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-22 | 2021-11-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-22 | 2021-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-22 | 2021-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-22 | 2021-11-10 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-09-17 | 2021-09-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-17 | 2021-09-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-14 | 2021-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-14 | 2021-08-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-14 | 2021-08-10 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-07-14 | 2021-08-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-14 | 2021-08-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-30 | 2021-05-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-30 | 2021-05-28 | Y |
