Inspection Reports for Allendale Rehabilitation And Healthcare Center
85 Harreton Road, Allendale, NJ, 07401
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
93% occupied
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, including how personal health information may be used and disclosed, and the rights individuals have regarding their health information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individual rights related to health information, legal duties of the department, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Annual Inspection
Census: 106
Capacity: 114
Deficiencies: 13
Date: Jun 21, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint # NJ172611 related to failure to maintain required minimum direct care staff-to-resident ratios.
Findings
Deficiencies were cited related to failure to report alleged violations timely, incomplete investigations, failure to provide bed hold policy notifications, inaccurate MDS coding, incomplete PASARR screening, medication administration documentation errors, incomplete post-assessment forms, incomplete monitoring sheets for medications, failure to maintain kitchen sanitation, failure to ensure infection preventionist certification, failure to maintain kitchen fire system inspections, and failure to maintain required staffing ratios.
Deficiencies (13)
Failure to report allegations of abuse within required timeframes to the New Jersey Department of Health.
Failure to thoroughly investigate allegations of abuse and injuries of unknown origin.
Failure to provide written notification of bed hold policy and reserve payment policy upon hospital transfer for residents.
Failure to accurately code Minimum Data Set (MDS) assessments for residents.
Failure to ensure Preadmission Screening and Resident Review (PASARR) was completed for a resident.
Failure to consistently follow standards of clinical practice regarding medication administration documentation, post-assessment forms, and monitoring sheets.
Failure to ensure kitchen staff comply with sanitation policies including jewelry restrictions.
Failure to ensure kitchen automatic fire-extinguishing system was inspected semi-annually as required.
Failure to ensure nonmetallic sheathed cable was protected by a 15-minute fire rating finish as required.
Failure to ensure infection preventionist had completed required specialized training prior to assuming role.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failure to provide residents two evening activity programs per week.
Failure to provide timely tuberculosis screening for new employees.
Report Facts
Census: 106
Total Capacity: 114
Deficiency counts: 12
Staffing ratios: 5
Staffing ratios: 4
Staffing ratios: 2
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 4
Date: Feb 1, 2023
Visit Reason
Complaint investigation based on multiple complaint intakes regarding compliance with long term care facility regulations.
Complaint Details
Complaint Intake #NJ160140, NJ158836, NJ156112, NJ155883, and NJ154287. The survey was conducted based on these complaints and found multiple deficiencies.
Findings
The facility was found not in compliance with several regulatory requirements including failure to notify resident representatives of changes, failure to ensure quality care and treatment, and failure to properly administer medications via enteral feeding tubes. Staffing ratios were also found to be below minimum requirements on some shifts.
Deficiencies (4)
Failed to notify resident's responsible party of abnormal lab results and new orders for Resident #1.
Failed to ensure quality care and treatment for Residents #1, #3, and #4 including failure to implement admission medications and obtain accurate lab tests.
Failed to administer medications through enteral feeding tubes according to physician orders for Residents #1, #7, and #9.
Failed to meet minimum staffing ratios for 2 of 42 shifts reviewed.
Report Facts
Census: 92
Sample Size: 13
Staffing ratio deficiency: 2
Certified Nurse Aides to Residents ratio: 7
Certified Nurse Aides to Residents ratio: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration deficiency related to enteral feeding tubes. |
| Director of Nursing | Director of Nursing | Interviewed regarding notification of changes and medication administration. |
| Administrator | Facility Administrator | Interviewed regarding notification of changes, staffing, and medication administration. |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding medication administration and admission orders. |
| RN #4 | Registered Nurse | Interviewed regarding medication administration and staffing. |
| Unit Manager #3 | Unit Manager | Interviewed regarding admission orders and staffing. |
| LPN #11 | Licensed Practical Nurse | Interviewed regarding medication administration. |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding medication administration. |
| LPN #12 | Licensed Practical Nurse | Interviewed regarding verbal orders and medication administration. |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 14
Date: Oct 11, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to accommodate resident needs, comprehensive care planning, medication labeling and storage, infection prevention and control, safe and sanitary environment, staffing ratios, and life safety code violations including egress doors, emergency lighting, fire alarm system, sprinkler system, corridor doors, HVAC, and electrical systems.
Deficiencies (14)
Facility failed to accommodate a resident's need and provide a functioning air conditioner.
Facility failed to develop a comprehensive person-centered care plan to include resident preferences.
Facility failed to properly label, store and dispose of medications in medication carts.
Facility failed to assure the Licensed Nursing Home Administrator attended the quarterly Quality Assurance meetings.
Facility failed to ensure staff handled clean linens and towels appropriately and failed to screen all staff entering the building for Covid-19 symptoms.
Facility failed to maintain a safe and sanitary environment in the folding and laundry rooms.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Facility failed to provide exit doors in the means of egress readily accessible and free of all obstructions or impediments to full instant use in case of fire or emergencies.
Facility failed to provide battery back-up emergency light above the emergency generator transfer switch.
Facility failed to provide fire alarm notification by audible and visible signals for an enclosed courtyard.
Facility failed to provide complete sprinkler coverage in the sunroom.
Facility failed to ensure corridor doors resist the passage of smoke and close completely.
Facility failed to ensure resident bathroom ventilation systems were adequately maintained.
Facility failed to certify the time needed by their generator to transfer power to the building within 10 seconds and failed to ensure a remote manual stop station for the generator.
Report Facts
Census: 87
Sample size: 20
Deficiency counts: 11
Staffing ratios noncompliance: 11
Dates with CNA staffing below minimum: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #75 | Resident | Named in air conditioning deficiency |
| Resident #4 | Resident | Named in comprehensive care plan deficiency |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Named in Quality Assurance Committee attendance deficiency |
| Maintenance Director | Maintenance Director | Named in multiple deficiencies related to maintenance and repairs |
| Regional Director of Plant Operations (RDPO) | Regional Director of Plant Operations | Named in multiple deficiencies related to maintenance and repairs |
| Director of Nursing (DON) | Director of Nursing | Named in infection control and Quality Assurance deficiencies |
| Risk Management Regional Nurse (RMRN) | Risk Management Nurse | Named in infection control deficiency |
| Regional Registered Nurse (RRN) | Regional Registered Nurse | Named in infection control and Quality Assurance deficiencies |
| Certified Nursing Assistant (CNA) | Certified Nursing Assistant | Named in infection control deficiency for failure to screen for Covid-19 |
| Laundry Aide #1 | Laundry Aide | Named in sanitary environment deficiency |
| Laundry Aide #2 | Laundry Aide | Named in sanitary environment deficiency |
| Housekeeping Director | Housekeeping Director | Named in sanitary environment deficiency |
Inspection Report
Life Safety
Deficiencies: 7
Date: Oct 11, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found noncompliant with several Life Safety Code requirements including egress door locking mechanisms, emergency lighting, fire alarm notification in enclosed courtyards, sprinkler system coverage, corridor door smoke resistance, bathroom ventilation, and essential electrical system maintenance and testing.
Deficiencies (7)
Exit doors in the means of egress were obstructed by keyed latches preventing rapid exit in emergencies.
Facility failed to provide battery back-up emergency light above the emergency generator transfer switch.
Fire alarm notification (horn/strobe) was not installed in an enclosed courtyard.
Sprinkler coverage was incomplete in the occupied sunroom, lacking sprinkler heads.
Corridor doors in 5 resident rooms did not close completely to resist passage of smoke.
Resident bathroom ventilation systems for 11 of 30 rooms were not functioning properly.
Facility failed to certify generator transfer time within 10 seconds and lacked remote manual stop station for generator.
Report Facts
Sets of exterior exit/egress doors observed: 2
Sets of doors with deficient egress: 3
Resident rooms with bathroom ventilation issues: 11
Resident room doors with smoke passage issues: 5
Generator load test dates missing transfer time: 12
Sunroom size: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies | |
| Regional Plant Operations Director | Present during observations and interviews related to deficiencies |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 3
Date: Apr 6, 2022
Visit Reason
The inspection was conducted based on complaints NJ151343 and NJ153512 alleging abuse, neglect, and failure to investigate incidents properly at the facility.
Complaint Details
Complaint numbers NJ151343 and NJ153512 triggered the visit. The complaint involved allegations of abuse, neglect, and failure to investigate injuries and mistreatment. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to thoroughly investigate allegations of abuse and injuries of unknown origin for Resident #3. The facility also failed to maintain a Universal Transfer Form for Resident #2 and did not meet minimum staffing ratios as required by New Jersey state law.
Deficiencies (3)
Failure to investigate an Injury of Unknown Origin and allegations of rough handling by staff for Resident #3, and failure to follow facility policies on abuse and change in resident condition.
Failure to maintain a completed copy of the Universal Transfer Form for Resident #2 as part of the medical record.
Failure to ensure minimum staff-to-resident ratios as mandated by New Jersey state law.
Report Facts
Census: 95
Sample Size: 4
Deficiencies cited: 3
Staffing ratio deficiency: 1
Staffing ratio deficiency: 1
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 2
Date: Sep 28, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00143264, NJ00147782, and NJ00148472 regarding infection prevention and control and staffing ratios.
Complaint Details
Complaint survey based on complaints NJ00143264, NJ00147782, and NJ00148472. The infection control complaint (NJ00143264) was substantiated with findings of uncovered clean linens. The staffing complaint (NJ00147782, NJ00148472) was substantiated with findings of inadequate staffing ratios for 37 of 126 shifts reviewed.
Findings
The facility was found non-compliant with infection prevention and control requirements due to uncovered clean linens in a busy area, and failed to maintain required minimum direct care staff-to-resident ratios for 37 of 126 shifts reviewed.
Deficiencies (2)
Failure to protect clean linens and blankets in a bin without a cover in a busy area.
Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Census: 78
Sample Size: 4
Shifts with inadequate staffing: 37
Staffing ratios: 12.1
Staffing ratios: 14.1
Staffing ratios: 20.5
Staffing ratios: 26.3
Staffing ratios: 27.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding uncovered linens but did not respond about covering linens | |
| Laundry Aide #2 (LA#2) | Provided information about linen bin usage and covering | |
| Licensed Nursing Home Administrator (LNHA) | Provided facility policy on linen handling and infection control | |
| Director of Nursing, Administrator, Staffing Coordinator | In-serviced on new minimum staffing requirements and involved in corrective actions |
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