Glen Arden Inc: Medical Director Never Worked Nursing Home - NY
During a September 5, 2024 interview, the medical director told inspectors he started his position on August 1 but didn't come to the facility to see residents until August 12. He didn't document notes in medical records when assessing residents, didn't know the regulations related to medical director responsibilities, and wasn't part of the facility's Quality Assurance Committee.
The medical director said he never conferred with the former medical director before starting his position. He didn't take part in staff meetings or Quality Assurance Committee meetings and wasn't introduced to staff since being hired. He told inspectors he wasn't familiar with working with a geriatric population.
The facility employed no nurse practitioner or physician assistant, making him the sole medical provider for residents.
The administrator, hired August 19, forgot the medical director's name during interviews with inspectors on September 4 and 5. She said she met the medical director for the first time on September 4, despite both working at the facility for weeks. The administrator couldn't provide information about the medical director's visits to the facility, hours worked, or billing for resident visits.
The facility didn't meet with residents or family members to introduce the new medical director.
The assistant administrator said the former administrator was responsible for interviewing the new medical director before his start date. She provided the medical director with contact information for the former medical director and encouraged communication to ensure continuity of resident care, but didn't confirm whether the two physicians actually spoke.
The assistant administrator met with the new medical director before his hire date but was unsure who approved hiring him.
Infection Control Failures
Inspectors found the facility failed to implement required infection prevention protocols for residents with medical devices. Two residents with indwelling tubes received care from staff who didn't follow enhanced barrier precautions.
Resident #22, who had a nephrostomy tube, was supposed to be on enhanced precautions according to physician orders dated May 17. The facility's own policy required staff to use gowns and gloves during high-contact care activities for residents with indwelling medical devices.
On June 25, inspectors observed a certified nurse's aide providing care to Resident #22 without wearing any personal protective equipment. The resident had a dressing with a white tube visible on his right lower back. No signage indicated enhanced barrier precautions were required, and no protective equipment cart was present.
Over three days of observations, inspectors never saw required signage or equipment carts outside Resident #22's room.
The certified nurse's aide told inspectors she never had to gown up while providing care to the resident and didn't remember being educated on enhanced barrier precautions. She only remembered "a paper going around to sign."
A registered nurse said she wasn't aware Resident #22 was on enhanced barrier precautions and hadn't seen staff gown up when providing care. Another certified nurse's aide said she wasn't aware of the precautions requirement and hadn't seen precaution signs or carts outside residents' rooms "since the pandemic."
The infection control preventionist acknowledged that residents with nephrostomy or urostomy tubes should have signs and protective equipment carts outside their doors.
Resident #19, who had a urostomy tube, also didn't have enhanced barrier precautions in place despite facility policy requiring them. No physician orders or care plans addressed the precautions requirement. The resident told inspectors that staff didn't wear gowns when helping with showers, and no protective signage or equipment was visible near the room.
Environmental Hazards
Inspectors documented multiple environmental safety issues throughout the facility. The kitchen freezer had a sheet of ice approximately half an inch thick covering the floor. The staff lounge and a housekeeping closet had stained ceiling tiles. In the ancillary services room, boxed medical supplies including gauze sponges, lift pads, sanitizing cloths, and razors were stored directly on the floor.
The food service director explained that the kitchen freezer accumulated ice due to condensation when hot kitchen air entered as the freezer door opened. The freezer had no drain. A new dietary worker was being trained to mop and clean the freezer floor regularly, but dietary staff hadn't reported concerns about icy conditions despite being responsible for doing so.
The director of environmental services said the facility planned to replace stained ceiling tiles once they stopped a leak on Unit 1 and repaired the roof. After inspectors showed her the ancillary services room, she said items would be removed from the floor and stored appropriately.
The administrator blamed ongoing negotiations for a nonprofit acquisition for renovation and repair delays. The Unit 1 ceiling leak occurred sporadically after rainstorms, and the facility had hired a roof repair company. She said the environmental services director checked a maintenance logbook daily where staff documented repair requests.
The facility's safety committee policy stated it was responsible for identifying environmental issues and managing safety concerns, but the documented hazards persisted during the multi-day inspection.
These violations occurred during a recertification survey conducted from June 25 through July 2, 2024, but interviews about the medical director's qualifications and oversight didn't happen until September, suggesting ongoing concerns about facility management and medical oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glen Arden Inc from 2024-07-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
Glen Arden Inc in GOSHEN, NY was cited for violations during a health inspection on July 2, 2024.
The medical director said he never conferred with the former medical director before starting his position.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Glen Arden Inc?
- The medical director said he never conferred with the former medical director before starting his position.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GOSHEN, NY, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Glen Arden Inc or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 335802.
- Has this facility had violations before?
- To check Glen Arden Inc's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.