Allendale Nursing and Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at Allendale Nursing and Rehabilitation Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 30, 2021

  This citation pertains to intake number MI 327. Based on observation, interview, and record review, the facility failed to prevent an elopement for Resident #11 reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy when Resident #11 (R11) who was assessed as an elopement risk, eloped from the front door of the facility, unbeknownst to staff, allowing R11 to ambulate away from the facility on 11/23/21 at approximately 4:30 PM, staff did not realize R11 was missing until 4:45 PM then returned to the facility approximately 5:00 PM by a good Samaritan who observed him walking down to the end of the subdivision and attempted to cross a 4 lane highway. […]

• Immediate jeopardy, isolatedF692Sep 22, 2021

  Based on observation, interview and record review, the facility failed to provide adequate nutrition monitoring and interventions for 3 residents (R 6, 63, and 117) of 6 residents reviewed for nutrition/hydration resulting in an Immediate Jeopardy (IJ) that began on 7/15/2021 when R 6's experienced a significant weight loss and the facility failed to notify the physician, failed to have R 6's chart reviewed by the regional dietician, failed to add additional interventions to prevent weight loss and R 6 continued to lose weight. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in harm, serious injury or death. […]

• Actual harm, isolatedF686Mar 26, 2026

  This citation pertains to intakes # 2801558 and 2807946Based on interview and record review, the facility failed to provide care following professional standards of practice and facility policy to prevent the development and/or worsening of pressure injuries for 3 of 5 residents (Resident #100, #42, and #41) reviewed for pressure injury prevention and management, resulting in a stage IV sacral decubitus ulcer with exposed bone and presumed osteomyelitis for R100.Findings:Resident #100 (R100)Review of an admission Record revealed R100 was a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted following a hospitalization from 6/12/25-6/26/25, with pertinent diagnoses which included: frontal brain mass resection, urinary incontinence, cognitive communication… […]

• Actual harm, isolatedF689Feb 12, 2026

  Based on observation, interview, and record review the facility failed to implement ordered safety precautions for two (Resident #43 and Resident #41) of three residents reviewed for accidents, resulting in Resident #43 eating meals unsupervised, choking and aspirating, and requiring emergency medical attention and hospitalization. Findings: Resident #43 (R43)Review of a Face Sheet revealed R43 was a [AGE] year-old female, last readmitted to the facility on [DATE] following hospitalization for a stroke that caused dominant (right sided) facial, arm, and leg weakness and paralysis. R43 depended on staff to meet all of her daily needs. […]

• Actual harm, isolatedF686Nov 30, 2022

  Based on observations, interviews, and record review, the facility failed to prevent and heal pressure ulcers for 3 Residents (R3, R7 and R44) resulting in R3 developing a stage 2 pressure ulcer and R7 and R44 developing unstageable pressure ulcers. Findings include: R3 Review of R3's face sheet, no date, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/29/22 at 1:28 PM, R3 was observed in the bathroom with CNA F. R3 had a 2 x 2 dressing over her coccyx with no date or initials for the treatment. R3 yelled out in pain when Certified Nurse Aide (CNA) F wiped her excoriated buttock after using the toilet. CNA F did not apply any barrier cream to R3's excoriated buttock. […]