Glen Arden Inc
Glen Arden Inc in Goshen, NY — inspection on July 2, 2024.
Found 13 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
6/25/2024 to 7/2/2024, the facility did not ensure each resident was treated with respect and
observation.
Specifically, Resident #37 and Resident #13 were not served lunch at the same time as their tablemates.
The findings are: The facility policy titled Open Dining dated 2/16/2007 documented residents participating in open-style dining will be able to dine at their preferred time and are served their meal according to the dining program.
On 6/25/2024 at 12:05 PM, Resident #37 and Resident #10 were observed in the dining room seated at the same table. Resident #10 received their meal tray and began eating their lunch. Resident #37 watched their tablemate eat lunch and asked a staff member for a lunch tray. Resident #37 was served their lunch tray at 12:14 PM.
On 06/27/2024 at 12:35 PM, Resident #13, #8, #36, and #10 were observed in the dining room seated at the same table. Resident #8, #36, and #10 were served their meal trays and began eating lunch. Resident #13 watched their tablemates eat while other residents in the dining room were served. Resident #13 commented they had not received their lunch and had no food to eat yet. At 12:43 PM, Resident #13 was served their lunch tray.
Residents #37 and #13 were not served lunch in a dignified manner to ensure they could begin eating at the same time as their tablemates.
On 07/02/2024 at 10:02 AM, the Food Service Director was interviewed and stated the nursing staff were responsible for seating the residents in the dining room in accordance with resident choice and ability to socialize.
The [NAME] or nursing staff arrange the meal tickets on the trays according to the posted seating chart to ensure residents were served consistent with their tablemates.
The consistency of meal tray service was affected when agency or temporary nursing staff in the dining room were unfamiliar with the residents.
On 07/02/2024 at 10:36 AM, the Director of Nursing was interviewed and stated they devised the dining room table seating chart along with the Director of Activities.
The seating chart was revised a few months prior and changed when the facility received new admissions or a resident's tablemate preference changed.
Nursing staff were aware of seating changes and, therefore, was responsible for setting up the tray tickets in preparation for meal service.
The nursing staff usually know the residents and where they sit. It is difficult to serve Resident #13 and their tablemates simultaneously because some of the residents have physical therapy sessions and arrive to the dining room later.
The Director of Nursing was not aware of inconsistencies with meal tray service amongst residents and their tablemates.
The nursing staff direct the dietary staff to ensure residents and their tablemates were served simultaneously. 10 NYCRR 415.3(d)(1)(i)
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
another nonprofit owner to acquire the facility has caused renovation and repair delays.
The carpeting
leak occurred sporadically after rainstorms.
The facility hired a roof repair company.
The
The Maintenance Department had a log book where staff documented their requests for repairs.
The Environmental Services Director checked the logbook daily.
The Administrator stated they also conducted environmental rounds of the facility when on site and communicated any observation concerns to the Director of Environmental Services. 10 NYCRR 415.29
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
Review of the facility's MDS assessment data completion and submission activities revealed that the following Minimum Data Set records exceeded 120 days from the date of completion and had not been submitted to the Centers of Medicare and Medicaid Services System Information until - Resident # 16: Discharge Minimum Data Set Assessment assessment dated [DATE] was rejected on 3/31/24 and had not been resubmitted until 6/25/24. -Resident # 18: Discharge Minimum Data Set Assessment assessment dated [DATE] was rejected on 3/31/24 and had not been resubmitted until 6/25/24.
During interview on 7/1/24 at 4:45 PM the Registered Nurse Minimum Data Set Specialist stated they usually ran reports to ensure all Minimum Data Set Assessments were accepted by Centers for Medicare and Medicaid Services, but had not run the report for the above Minimum Data Set Assessments until 6/25/24.
The Registered Nurse Minimum Data Set Specialist stated when the report was run they noted that the 2 assessments had been rejected due to information in section A.
NY [NAME] 415.11
During observation on 06/25/24 at 11:11 AM: Resident #10 was in bed stating talk louder. I can't hear you. Resident #10 was unable to respond appropriately to questions being asked and stated come closer. Resident #10 was requesting to be toileted and had noticeable joint stiffness of the bilateral hands.
There was no documented evidence in the electronic medical record that person-centered care plans with measurable objectives, time frames and appropriate interventions were developed to address hearing impairment, toileting and/or incontinence, and position/mobility/or range of motion prior to 6/26/24.
During interview on 06/27/24 at 11:42 AM. Resident #10's son stated Resident #10 had hearing aids for many years in the past.
Hearing aids on admission were not functioning due to the age of devices and needed to be replaced.
Family did not wish to pursue offsite audiology visit.
Son sent a pair of hearing devices about 2 years ago, but they did not work out.
Son stated the staff made efforts to communicate effectively with the resident. Resident #10's son stated the resident had severe rheumatoid arthritis of the hands for many years.
The resident was right -handed and tended to focus on the right side.
Resident# 10's son stated they had to locate staff during visits to assist Resident #10 with toileting needs.
During an interview on 7/1/24 at 11:28 AM the Director of Nursing stated they were responsible for ensuring care plans were developed and that interventions were effective.
The Director of Nursing stated they were not always able to keep up. 10NYCRR 415.11(c)(1)
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
from chair to bed; respond promptly to calls for assist to the toilet.
Toilet between 6 AM and 7AM; use
footwear/nonskid footwear with rubber soles; Evaluate for orthostatic hypotension; Rehab screen to assess need for therapy/positioning--assistive devices as indicated; Use diversional activities and encourage participation in activities.
Accident Incident Report dated 11/4/23 documented resident had a fall and recommendation for floor mat and 15-minute monitoring.
No documented evidence care plans were revised to include floor mats.
On 7/1/24 at 2:34 PM Director of Nursing stated they were responsible for the care plans.
Director of Nursing stated they may not have updated the care plan but the staff were made aware of any interventions that were made from any recommendations made. [10 NYCRR 415.11(c)(2)(iii)]
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
During an interview on 06/27/24 at 03:52 PM, the Medical Director stated that they were recently at the facility and was not notified that Resident #22 was itching and scratching their skin causing excoriations and did not receive any correspondences from nursing staff prior to or after their recent visit to the facility.
The Medical Director stated that Resident #22 has end stage renal disease which causes dry and itchy skin, and that regular lotion would not relieve the symptoms and they would prescribe a moisturizing cream for staff to apply to Resident #22's skin.
Furthermore, the Medical Director stated that Resident #22 should have had moisturizing cream prescribed to be given as needed. 10 NYCRR 415.11(c)(2)(ii)
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
Therapist #1 stated when they wrote their notes with recommendations for changes, it was the
they liked to go the common area but most of the time the staff did not bring them there.
On 7/01/24 at 2:34 PM, the Director of Nursing stated the staff were aware of the toileting schedule and they were not sure why it was not implemented.
They stated the care plan might not have been updated, but the staff were made aware.
The alarm on the bathroom door was supposed to be turned on all the time and the resident would get annoyed and would turn it off with their reacher (device used to assist in grabbing items that the resident cannot reach).
The Director of Nursing stated the staff should still be using the alarm.
The Director of Nursing stated when toileting the resident the Certified Nurse Assistant must stay in the room or right outside of the bathroom to give them privacy but should not be down the hall.
The Director of Nursing stated Resident #12 sustained a hematoma and fractured ribs with the fall in May 2024, and did not remember the time the resident fractured ribs in September 2023.
The Director of Nursing stated when Resident #12 was in the recliner the staff checked on them but there was not documentation of that monitoring.
The Director of Nursing stated the staff should be checking on Resident #12 often but would not specify how often. 415.12(h)(2)
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
During an interview on 07/01/24 at 10:43 AM, the Director of Nursing stated that the expired equipment was not supposed to be in the medication storage room and that they would discard them.
The Director of Nursing stated that they were in possession of the key to the storage room and that they were responsible for going through the things that were kept in there, especially for expired medications.
The Director of Nursing stated that nothing should be expired in the med room whether it was being used or not, and stated they would get rid of the expired items and go through the rest of the storage room to see if anything else was expired and needed to be discarded. 10NYCRR 483.45 (g)(h)
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
During an interview with Resident #141 on 6/25/24 at 11:08 AM, they stated the food was constantly cold at dinner time. Resident #141 stated they could not recall the exact date but about 2 weeks ago they plated food, and it took 30 minutes to deliver trays.
During an observation on 6/27/24 at 12:11 PM, while servers were prepping food for tray distribution from steam table, temperatures were taken on the shrimp salad, cucumber salad, baked chicken, fish and apricots.
The Food Service Director put the thermometer in the shrimp salad and the temperature was taken and read 50 degrees Fahrenheit, the baked chicken was 127.5 degrees Fahrenheit, and the apricots were 46 degrees Fahrenheit.
When interviewed on 7/02/24 at 10:02 AM, the Food Service Director stated the hot/cold station steam table just started being used about 6 months ago.
Food Service Director stated the steam table station did keep the temperatures at an acceptable level.
Food Service Director stated the hot food should be over 140 degrees (F) and the cold food should be under 40 degrees (F). 10NYCRR 415.14(d)(1)(2)
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policies and coordination of medical care in the facility.
9/3/2024 to 9/5/2024, the facility did not ensure the medical director was responsible for
Specifically, the new Medical Director hired on 8/1/2024 was unaware of their responsibilities as a medical director and had no previous nursing home experience, was not a part of the quality assurance committee, and did not assess residents until 12 days after hire date.
The findings are: The facility Medical Director Agreement dated 7/29/2024 documented the Medical Director shall be responsible for assuring each resident's responsible physician attends to the resident's medical needs, participates in care planning, follows the schedule of visits in accordance with 10 NYCRR 415.15(b), and complies with the facility policies, rules, regulations, and medical staff by-laws.
Please refer to 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.
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 Assistant Administrator provided the Medical Director with the contact information for the former Medical 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 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)
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Glen Arden Inc 214 Harriman Drive Goshen, NY 10924
During an interview on 06/27/24 at 11:46 AM, Staff #3(certified nurse's aide) stated they were not
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 [DATE] 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)
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concerns to the Director of Environmental Services.
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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.
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Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.