Glen Arden Inc

F-F689.

On 9/5/2024 at 3:54 PM, the Medical Director was interviewed and stated they were the only physician on staff at the facility. The facility did not employ a Nurse Practitioner or Physician Assistant. The Medical Director stated they did not confer with the former Medical Director of the facility before starting their position

on 8/1/2024, did not come to the facility to see residents until 8/12/2024, did not document their notes in the medical record upon assessing or visiting with residents, did not know the regulations related to Medical Director responsibilities in the State Operations Manual, and was not part of the facility Quality Assurance Committee upon being hired. The Medical Director did not take part in any staff meetings, did not take part in any Quality Assurance Committee meetings, and was not introduced to staff since being hired. The Medical Director stated they have never worked in a skilled nursing facility prior to being hired by the facility and was not familiar with working with a geriatric population.

On 9/4/2024 at 2:05 PM and 3:31 PM and 9/5/2024 at 6:56 PM, the Administrator was interviewed and stated they were hired by the facility on 8/19/2024 and forgot the name of the new Medical Director that was hired by the facility on 8/1/2024. The Administrator stated they just met the new Medical Director on 9/4/2024 for the first time. The Administrator stated the facility did not meet with residents or family members to introduce the new Medical Director. The Administrator was unable to provide information related to Medical Director visits to the facility, hours at the facility, or billing for resident visits since their hire date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 335802 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335802 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glen Arden Inc 46 Harriman Drive Goshen, NY 10924

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0841 On 9/5/2024 at 7:01 PM, the Assistant Administrator was interviewed and stated the former Administrator was responsible for interviewing the new Medical Director prior to their start with the facility on 8/1/2024. The Level of Harm - Minimal harm or Assistant Administrator provided the Medical Director with the contact information for the former Medical potential for actual harm Director and encouraged them to communicate to ensure the new Medical Director was acclimated to the facility and continuity of resident care between physicians. The Assistant Administrator stated they did not Residents Affected - Some confirm whether the former Medical Director and the new Medical Director communicated with each other.

The Assistant Administrator stated they met with the new Medical Director prior to their hire date but was unsure who was responsible for approving the hiring of the new Medical Director to work at the facility.

10 NYCRR 415.26(e)(1)(i-iv)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 335802 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335802 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glen Arden Inc 46 Harriman Drive Goshen, NY 10924

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45478 potential for actual harm 48847 Residents Affected - Few Based on observation, record review, and interviews conducted during the recertification survey from 6/25/24-7/02/2024 the facility did not ensure an infection prevention and control program was designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #19 and #22) of 4 residents reviewed. Specifically, Resident #19 had a urostomy tube and Resident #22 had a nephrostomy tube, and enhanced barrier precautions were not implemented.

Findings include:

The facility's policy titled Transmission Based Precautions/Enhanced Barrier Precautions dated 12/15/2022 documented that enhanced barrier precautions are meant to prevent the spread of multi drug resistant organisms. They are used with all residents with indwelling medical devices. The principles of Enhanced Barrier precautions are that staff will use a gown and gloves during high contact resident care activities only and is intended to be used for resident's entire length of stay; or while they have indwelling devices/wounds.

1) Resident #22 was admitted with diagnoses including acute pyelonephritis, diabetes, and end date renal disease. The Quarterly Minimum Data Set, dated dated dated [DATE REDACTED] documented Resident #22 had moderately impaired cognition, was independent with eating, and required total assistance with bed mobility, toileting, and transfers.

Physician orders dated 5/17/24 documented Resident #22 was on enhanced precautions due to Nephrostomy tube.

Review of the Care Plans revealed that there was no Enhanced Barrier Precautions care plan.

On 06/25/24 at 10:22 AM, Resident #22 was observed in their room sitting on bed while Staff #6(certified nurse's aide) was observed in room providing care to resident and assisting them out of bed. There was a dressing with a white tube observed on the resident's right lower back. Resident #22 stated that they had a nephrostomy tube. Staff #6 was observed not wearing any personal protective equipment while giving care. There was no signage on the door indicating Resident #22 was on Enhanced Barrier Precaution, and there was not a personal protective equipment cart in sight.

On 06/25/24 at 10:53 AM, Resident #22 was observed in their room and there were no enhanced barrier precautions signage observed on the resident's door or a personal protective equipment cart in sight.

On 06/26/24 at 09:40 AM, Resident #22 was observed in their room and there were no Enhanced Barrier Precautions signage observed on the door and no personal protective equipment carts in sight.

On 06/27/24 at 11:38 AM, there were no Enhanced Barrier Precautions signage or personal protective carts outside of the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 335802 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335802 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glen Arden Inc 46 Harriman Drive Goshen, NY 10924

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 06/27/24 at 11:27 AM, Staff #6(certified nurse's aide) stated that Resident #22 had a nephrostomy tube and that they required extensive assistance with activities of a daily living. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/27/24 at 11:34 AM, Staff #1(registered nurse) stated that they were not aware that Resident #22 was on Enhanced Barrier Precautions and had not seen staff gown up when providing cares to Residents Affected - Few the resident.

During an interview on 06/27/24 at 11:46 AM, Staff #3(certified nurse's aide) stated they were not aware that Resident #22 was on Enhanced Barrier Precautions and had not seen any precautions signs or carts outside of the resident's room since the pandemic. Staff #3(certified nurse's aide) stated that they did not wear a gown when they provided care to the resident.

During an interview on 06/27/24 at 11:47 AM, Staff #6(certified nurse's aide) stated that they never had to gown up while providing cares to Resident #22 and did not remember being educated on enhanced barrier precaution, they only remembered a paper going around to sign.

During an interview on 06/27/24 at 12:02 PM, the Infection Control Preventionist stated that if a resident had

a nephrostomy or urostomy tube, they should have had a sign and a personal protective equipment cart outside of their door.

During an interview on 06/27/24 at 12:06 PM, the Director of Nursing stated that Resident #22 should have been on Enhanced Barrier Precautions and there should have been a sign on the door with instructions and

a personal protective equipment cart outside of the room.

2) Resident #19 was admitted with diagnoses including acute kidney failure, metabolic encephalopathy, and ostomy in place to right lower middle abdomen. The Admission Minimum Data Set, dated dated dated [DATE REDACTED] documented Resident #19 had intact cognition, was independent with eating, and required moderate assistance with bed mobility, toileting, and transfers, and had an ostomy.

Review of the physicians' orders and the care plans revealed that there were no Enhanced Barrier Precautions in place.

On 6/27/24 at 12:43 PM, Resident #19 was observed in their room and stated that they had a urostomy tube. Resident #19 stated that although they did not require assistance with routine activities of a daily living, they did require assistance with showering and staff did not wear gowns when giving them shower. There was no Enhanced Barrier Precautions signage observed on the door or any personal protective equipment observed near their room.

10 NYCRR 415.19(a)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 335802 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335802 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glen Arden Inc 46 Harriman Drive Goshen, NY 10924

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 40686

Residents Affected - Some Based on observation, interview, and record review conducted during the recertification survey from 6/25/2024 to 7/2/2024, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public was provided. This was evident during environmental observation of the kitchen, staff lounge, housekeeping closet, and ancillary services room. Specifically, a sheet of ice was observed covering the kitchen freezer floor, the staff lounge and housekeeping closet had stained ceiling tiles, and the ancillary services room had several items stored on the floor.

The findings are:

The facility policy titled Safety Committee Policy dated 4/21/2024 documented the Safety Committee was responsible for identifying issues pertaining to the environment and managing safety, and hazardous materials and wastes.

On 06/25/24 at 10:01 AM, 6/26/2024 from 9:30 AM to 5:00 PM, and 6/27/2024 from 9:30 AM to 5:00 PM, the facility was observed with the following:

- staff lounge locker room and bathroom with stained ceiling tiles,

- the ancillary services room had boxed supplies containing gauze sponges, Hoyer lifter pads, Sani-cloths, and razors stored directly on the floor,

- the kitchen freezer had a sheet of ice approximately a 1/2 inch thick covering the floor.

On 6/27/2024 at 4:00 PM, the Director of Environmental Services was interviewed and stated the facility planned to replace the stained ceiling tiles throughout the facility once they stopped a leak on Unit 1 and repaired the roof. After observing the ancillary services room, the Director of Environmental Services stated

they would ensure all items were removed from the floor and stored appropriately. The kitchen freezer floor was cleaned daily by housekeeping staff at the end of each shift.

On 07/02/2024 at 10:02 AM, the Food Service Director was interviewed and stated the kitchen freezer accumulated ice on the floor due to condensation. As the freezer door opens, the hot air from the kitchen causes condensation in the freezer that drips and then freezes on the freezer floor. The freezer did not have

a drain. A new dietary worker was recently hired and was in the process of being trained on their responsibility to mop and clean the freezer floor regularly to prevent ice from forming. The dietary staff were responsible for reporting concerns related to icy freezer floors to the Food Service Director but have not reported any concerns. The Food Service Director stated they conducted daily rounds of the kitchen and provided oversight of the dietary staff to ensure they performed their job duties.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 335802 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335802 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glen Arden Inc 46 Harriman Drive Goshen, NY 10924

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 On 07/02/2024 at 10:45 AM, the Administrator was interviewed and stated ongoing negotiations for another nonprofit owner to acquire the facility has caused renovation and repair delays. The Unit 1 ceiling leak Level of Harm - Minimal harm or occurred sporadically after rainstorms. The facility hired a roof repair company. The Maintenance potential for actual harm Department had a logbook where staff documented their requests for repairs. The Environmental Services Director checked the logbook daily. The Administrator stated they also conducted environmental rounds of Residents Affected - Some the facility when on site and communicated any observation concerns to the Director of Environmental Services.

10 NYCRR 415.29

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 335802