Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allendale Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Deficiencies were identified in infection control practices, including a CNA failing to change gloves or perform hand hygiene during incontinent care for a resident with severe cognitive impairment, improper separation of clean and soiled laundry with inadequate PPE in the laundry area, and an incomplete water management program for Legionella lacking documentation and testing protocols.
The facility failed to adhere to its kitchen sanitation policy, as observed by a surveyor who noted the Food Service Director and a Dietary Aide wearing prohibited jewelry. This violation of the hygiene policy, which mandates minimal jewelry and proper coverage during food handling, was acknowledged by the FSD.
The facility inaccurately coded the MDS for three residents, affecting the management of their care. One resident's MDS did not reflect dialysis treatment, another's failed to indicate hospice care and flu vaccination status, and a third's discharge location was incorrectly recorded. The errors were acknowledged by the MDS Coordinator and the LNHA.
A facility failed to complete a PASRR for a resident diagnosed with paranoid schizophrenia. The resident's medical records showed diagnoses of heart failure, anxiety disorder, major depressive disorder, and schizophrenia, with the onset of schizophrenia occurring during their stay. Despite this, no PASRR Level I screen was documented. Interviews revealed that a PASRR should have been completed prior to admission and for new serious mental disorders, but it was only done after surveyor inquiry.
A long-term care facility failed to adhere to professional standards, resulting in deficiencies in documentation and monitoring. A resident's MAR had numerous unsigned entries for insulin and other medications, while another resident's dialysis communication records were incomplete. Additionally, behavior and side effect monitoring for a resident with anxiety and depression were not consistently documented. These lapses were acknowledged by the facility's staff, including the LPN and DON.
A resident with dysphagia and moderately impaired cognition was supposed to receive enteral nutrition through a bolus feeding method six times daily, but was only receiving it five times daily due to an unaddressed order discrepancy. The LPN and RD failed to identify and correct the error, which was contrary to the facility's policy requiring complete orders for enteral nutrition.
A CP failed to clarify the medication route for a resident with dysphagia and an NPO order, leading to an inappropriate oral medication order. The CP's reviews did not identify this issue, despite facility policy requiring quarterly medication administration record reviews.
The facility failed to ensure that the designated Infection Preventionist (IP) completed the required specialized training before assuming the role. The IP was hired and signed a job description on 6/10/21, but the training certificates showed completion dates from August 2021, indicating the training was not completed prior to starting the role. This discrepancy was confirmed during interviews with the IP and facility staff.
A facility failed to report an abuse allegation within the required two-hour timeframe to the NJDOH. The incident involved a resident being hit by a confused roommate. The event occurred late at night, but the report was delayed by two days. The facility's policy mandates immediate reporting within two hours for such incidents, but this was not followed.
A resident with severe cognitive impairment was found with a swollen thumb, but the facility failed to complete a thorough investigation. The investigation lacked interviews from the staff on the shift prior to the injury being identified, contrary to the facility's policy requiring staff interviews over the prior 48 hours.
The facility failed to provide written notification of its bed hold and reserve payment policy to two residents upon hospital transfer. The Business Office Manager confirmed that notifications were mailed and calls were made, but documentation lacked necessary details, leading to the deficiency.
Infection Control Deficiencies in Resident Care, Laundry Handling, and Water Management
Penalty
Summary
The facility failed to maintain proper infection control measures in three key areas. During incontinent care for a resident with severe cognitive impairment and bowel and bladder incontinence, a CNA did not remove soiled gloves or perform hand hygiene after providing peri care and before continuing to clean the resident's legs. The CNA confirmed during an interview that she did not change gloves or use hand hygiene, and the DON acknowledged awareness of infection control protocols but noted the CNA should have known better. In the laundry area, clean and soiled linens were not adequately separated. Soiled laundry was sorted on the unit and brought into the laundry room, then after washing and drying, clean laundry was transferred across a soiled area to a folding room. The laundry room lacked appropriate PPE such as gowns, gloves, or masks, and disinfectant was stored with clean items. The Infection Preventionist was not aware of the issue with clean linen passing through the soiled area. Additionally, the facility's water management program for Legionella was incomplete, lacking documentation of water flow, identification of potential pooling sites, and testing protocols, as confirmed by the Maintenance Director.
Improper Kitchen Sanitation Practices Observed
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, which could potentially lead to foodborne illness. During a kitchen tour, the surveyor observed the Food Service Director (FSD) and a Dietary Aide (DA#1) wearing earrings that hung more than one inch from their earlobes, which is against the facility's policy on employee hygiene and sanitary practices. The policy, revised in November 2022, specifies that jewelry should be kept to a minimum and that hand and wrist jewelry should be covered with gloves during food handling. Despite this policy, both the FSD and DA#1 were found to be in violation, as acknowledged by the FSD during the observation.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of their care. For one resident, the MDS did not indicate that the resident received dialysis treatment, despite the resident's medical record showing a diagnosis of end-stage renal disease and dependence on renal dialysis. The MDS Coordinator acknowledged the error after it was pointed out by the surveyor. Another resident's MDS failed to identify the resident as being under hospice care and inaccurately recorded the status of a flu vaccine, which was documented as received in the resident's immunization record. The MDS Coordinator admitted that the hospice care status was missed during the assessment. For the third resident, the discharge MDS inaccurately recorded the resident as being discharged to an acute hospital, while the interdisciplinary progress notes indicated the resident was discharged to home. The facility's policy on discharge assessments was reviewed, and it was found that the MDS was not coded correctly. The Licensed Nursing Home Administrator confirmed the inaccuracies in the MDS coding for all three residents.
Failure to Complete PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosis of paranoid schizophrenia. The resident, who was alert and oriented, was observed by a surveyor, and their medical records were reviewed. The records indicated that the resident had diagnoses including heart failure, anxiety disorder, major depressive disorder, and paranoid schizophrenia, with the onset of schizophrenia occurring during their stay at the facility. Despite these diagnoses, there was no documentation of a PASRR Level I screen being completed for the resident during their time at the facility. Interviews with the Social Worker and the Director of Social Services revealed that a PASRR Level I screen should have been completed prior to admission and that a new onset of a serious mental disorder, such as schizophrenia, during the resident's stay should have prompted a PASRR screen. The Director of Social Services confirmed that a PASRR Level I was only completed after the surveyor's inquiry and that any prior PASRR could not be found. The facility's policy required a Level I PASRR screen for all admissions, but this was not adhered to in the case of the resident, leading to the deficiency.
Deficiencies in Documentation and Monitoring in LTC Facility
Penalty
Summary
The facility failed to consistently follow professional standards of clinical practice, as evidenced by multiple deficiencies in documentation and monitoring. One resident, who was diabetic, had numerous unsigned entries in their Medication Administration Record (MAR) for insulin administration, blood sugar checks, and other medications over several months. The Licensed Practical Nurse (LPN) acknowledged that the MAR should be signed at the time of medication administration, and the Director of Nursing (DON) confirmed the expectation for complete documentation. However, the facility's policy on medication administration was not adhered to, resulting in blank entries for critical medications. Another deficiency was observed with a resident who required dialysis. The Dialysis Communication Binder, which should have been completed by the facility upon the resident's return from dialysis, had multiple blank entries. The LPN admitted to not filling out the post-dialysis assessment, and the Unit Manager confirmed that the Hemodialysis Communication Record (HCR) should be completed by the nurse. Despite the facility's policy on dialysis communication, the necessary documentation was not completed, leaving gaps in the resident's care records. Additionally, a resident with chronic obstructive pulmonary disease, anxiety disorder, and depression had incomplete behavior and side effect monitoring records. The June 2024 MAR/Treatment Administration Record (TAR) showed numerous blanks for behavior monitoring and side effect monitoring, which were supposed to be documented every shift. The LPN and Unit Manager both acknowledged the importance of this monitoring to assess the necessity and effectiveness of medications. However, the facility's policy on behavioral assessment and monitoring was not followed, resulting in incomplete documentation.
Enteral Feeding Order Discrepancy
Penalty
Summary
The facility failed to identify and accurately address an Enteral Feeding (EF) order discrepancy for a resident who was receiving tube feeding. The resident, who had moderately impaired cognition and was diagnosed with dysphagia following a cerebral infarction, was supposed to receive enteral nutrition through a bolus feeding method. The physician's order indicated that the resident should receive Jevity 1.5 Cal 237 ml six times per day, but the Medication Administration Record (MAR) showed that the resident was only receiving the feeding five times daily. This discrepancy was not identified by the facility staff, including the Licensed Practical Nurse (LPN) overseeing the resident's care and the Registered Dietitian (RD) responsible for monitoring the resident's nutritional needs. The surveyor's investigation revealed that the LPN had not previously observed the error in the feeding order and acknowledged the need for clarification. The RD also confirmed that the order should have been for six feedings per day but could not explain why the error was not caught earlier. The facility's policy on enteral feeding requires that orders be complete and include the product, administration method, and volume and rate of administration. However, this policy was not adhered to, resulting in the resident receiving inadequate nutrition as per the prescribed order.
Consultant Pharmacist Fails to Clarify Medication Route for NPO Resident
Penalty
Summary
The Consultant Pharmacist (CP) failed to clarify the medication route for a resident during the monthly medication reviews. This deficiency was identified for one of six residents, specifically a resident who was admitted with diagnoses including dysphagia following a cerebral infarction and severe protein-calorie malnutrition. The resident's medical records indicated a physician order for a Nothing by Mouth (NPO) diet and tube feeding, yet there was an order for Ascorbic Acid to be administered orally, which was not appropriate given the resident's condition. The CP's medication reviews for April and May did not identify any issues with the resident's medication orders, despite the inconsistency with the resident's NPO status. During an interview, the CP acknowledged missing the error in the medication route, which should have been administered via the PEG tube instead of orally. The facility's policy required the CP to review medication administration records quarterly and document any concerns, but this was not adhered to in this instance, leading to the oversight.
Infection Preventionist Lacked Required Training Before Role Assumption
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had completed the required specialized training in infection prevention and control as per CMS guidance before assuming the role. The IP was hired on 6/10/21, and the job description signed by the IP acknowledged the necessity of specialized training. However, the training certificates provided by the facility showed completion dates ranging from 8/07/21 to 8/23/24, indicating that the IP did not complete the necessary training before starting the role. During an interview, the IP confirmed the date of hire and acknowledged that the specialized training was completed in August 2021, after assuming the role. The Licensed Nursing Home Administrator (LNHA) and other facility staff were informed of this deficiency, and the LNHA noted that the IP's job description was updated when the facility was acquired by a new company. However, the timeline provided by the facility did not align with the job description, further highlighting the discrepancy in the IP's training timeline.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the New Jersey Department of Health (NJDOH). The incident involved a resident who was hit by a confused roommate with occasional aggressive behaviors. The event occurred on March 18, 2023, at 11:00 PM, but the report was not submitted to the NJDOH until March 20, 2023, at 3:00 PM. The facility's Reportable Event Record (RER) was incomplete, lacking documentation on whether the incident was significant and if it was called in. The resident involved was awake, alert, and oriented, and expressed that they were okay and did not wish to press charges. The resident was immediately transferred to another room, and no injuries were noted. Interviews with the Director of Nursing (DON) revealed that the incident should have been reported within two hours, regardless of whether the abuse was substantiated. The DON, who had been at the facility for only three weeks, confirmed the reporting requirement. The facility's policy on abuse reporting, revised in September 2022, mandates immediate reporting of abuse allegations to the administrator and relevant authorities within two hours if the incident involves abuse or results in serious bodily injury. Despite this policy, the facility did not adhere to the required reporting timeframe.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment. The resident, who had a history of essential hypertension, unspecified dementia, and anxiety, was found by a family member to have a swollen and discolored left thumb. This injury was reported to a nurse, and a facility reportable event was documented. However, the investigation was incomplete as it lacked interviews from the staff on the shift prior to the injury being identified, specifically the 11-7 shift on the day before the injury was noted. The facility's policy required interviews and statements from staff over the prior 48 hours when an injury of unknown source was identified. Despite this, the investigation did not include statements from the nurse and CNA who worked the 11-7 shift before the injury was discovered. The Director of Nursing and the Regional Director of Operations acknowledged the oversight and the importance of these interviews in completing the investigation. The facility's policies on investigating resident injuries and reporting abuse were not fully adhered to, as the necessary staff interviews were not conducted.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide appropriate written notification of its bed hold and reserve payment policy to residents or their representatives upon transfer to a hospital. This deficiency was identified for two residents who were reviewed for hospitalizations. For the first resident, the medical record did not include a written notification of the bed hold policy prior to the transfer to the hospital. The Business Office Manager (BOM) stated that she would leave a message and mail a letter regarding the policy, but no additional information was provided at the time of transfer. The surveyor noted that the facility's documentation did not include the payor information, which is a critical component of the bed hold policy. For the second resident, the medical records indicated a transfer to an acute care hospital, but there was no evidence of a written notification of the bed hold policy being provided. The BOM confirmed that the policy was mailed and that a call was made to the resident's representative. However, the facility's policy documentation was undated and lacked specific details required by state regulations, such as the rights and limitations regarding bed holds and the facility's per diem rate for holding a bed. This lack of proper documentation and communication led to the identified deficiency.
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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.
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Nursing homes near Allendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodcliff Lake Health & Rehabilitation Center | 2.6 mi | — | 0 | 0 |
| Ridgewood Center | 3.7 mi | — | 0 | 0 |
| The Willows At Ramapo Rehab And Nursing Center | 4 mi | — | 17 | 0 |
| Family Of Caring At Park Ridge Llc | 4.6 mi | — | 3 | 0 |
| Christian Health Care Center | 5 mi | — | 13 | 0 |
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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 August 2026) and official state health department websites.