Glen Arden Inc

Inspectors wroteBased on interview, observation and record review during the survey, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and to prevent worsening of pressure ulcers. This was evident for one (1) of three (3) residents (Resident #11) reviewed for pressure ulcers. Specifically, Resident #11 was assessed as at risk for pressure ulcers on admission and had no pressure ulcers. There was no documented evidence that offloading practices or turning and positioning were implemented to prevent pressure ulcers from developing. On 11/23/2025, a Stage 2 (damage to skin or underlying soft tissue) pressure ulcer to their left heel was identified. On 12/09/2025, Resident #11's left heel wound had progressed to a Stage 4 pressure ulcer (full thickness skin and tissue loss). [...]

Inspectors wroteBased on observation and interview the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, 1) unsealed, unlabeled, and undated foods were stored in the refrigerators and freezer, 2) expired foods were stored in the dry pantry, walk in cooler, and reach- in refrigerator, and 3) staff were observed not wearing hair and beard restraints while in the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that each resident was treated in a manner that maintained or enhanced each resident's dignity and respect for one (1) resident (Resident #32) reviewed for dining. Specifically, Resident #32's meal tray and feeding assistance were not provided at the same time another resident (Resident #23) at the same table was provided their meal tray and feeding assistance. Additionally, once served, Registered Nurse #18 stood over Resident #32 while they provided the resident with feeding assistance.

Inspectors wroteBased on record review and interview the facility did not ensure the development and implementation of comprehensive person-centered care plans that included measurable objectives and timeframes to meet the resident's medical, nursing, and nutrition needs for one (1) of one (1) resident (Resident #20) reviewed for Tube Feeding. Specifically, there was no documented evidence that a comprehensive care plan with goals and interventions was developed to address Resident #20's tube feeding and nothing by mouth status as per the 11/29/2025 physician order.

Inspectors wroteBased on record review and interview the facility did not ensure that medical supervision was provided for one (1) of three (3) residents (Resident #11) reviewed for pressure ulcers. Specifically, Resident #11 was diagnosed with a left heel Stage 2 pressure ulcer, and the primary physician did not address recommendations by the wound care physician on 11/25/2025 or 12/02/2025 or 12/09/2025. Subsequently, two (2) weeks later Resident #11's left heel wound was classified as unstageable, was surgically debrided on 12/09/2025 and then classified as a Stage 4 pressure ulcer (full thickness skin and tissue loss).

Inspectors wroteBased on interview and record review the facility did not ensure that certified nurse aides had a performance review completed every 12 months. Specifically, one (1) of four (4) certified nurse aides (Certified Nurse Aide #5) did not have a performance review completed in the last twelve months.

Inspectors wroteBased on record review, observation and interview conducted during a recertification survey the facility failed to ensure that adequate supervision and effective use of the facility's monitoring program to prevent falls and injuries were provided for 2 of 3 residents reviewed for accidents (Resident #10 and #12). Specifically, (1) Resident #10 was care planned to be on 30-minute monitoring after a 4/12/24 fall. Resident #10 had a second fall on 4/14/24 which resulted in a nondisplaced transverse fracture of the distal malleolus (a break in the small prominent bone on either side of the ankle) and the facility did not implement care plan changes to address recurrent falls and (2) Resident #12 had 6 falls between 9/16/23 and 5/3/24 and the facility did not implement new interventions, including toileting schedules and monitoring, as recommended on the Accident/Incident reports. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 6/25/2024 to 7/2/2024, the facility did not ensure residents' right to a safe, clean, comfortable and homelike environment. This was evident during environmental observation of resident Unit 1 and Unit 2. Specifically, 1) Unit 1 was observed with a ceiling leak, stained and uneven carpeting, and stained ceiling tiles, and 2) Unit 2 was observed with broken bathroom floor tiles, stained, frayed, and uneven carpeting, and a broken desk in the nourishment station.

Inspectors wroteBased on observation, interview, and record review conducted during the post-survey revisit from 9/3/2024 to 9/5/2024, the facility did not ensure the medical director was responsible for implementation of resident care policies and the coordination of medical care in the facility. 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 6/25/2024 to 7/2/2024, the facility did not ensure each resident was treated with respect and dignity. This was evident for 2 (Resident #13 and Resident #37) of 18 sampled residents during dining observation. Specifically, Resident #37 and Resident #13 were not served lunch at the same time as their tablemates.

Inspectors wroteBased on record review, observation and interview conducted during a recertification survey, the facility did not develop and implement a person-centered care plan with measurable objectives and time frames in accordance with comprehensive assessments for one of one resident reviewed for Communication-Sensory and Incontinence and one of three residents reviewed for Positioning / Mobility (R #10). Specifically, for Resident #10 comprehensive care plans were not developed and/or implemented to address hearing impairment to allow for clear communication between facility staff and Resident #10, bladder and bowel incontinence, and to address bilateral hand joint stiffness related to rheumatoid arthritis.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 1 of 3 residents (Resident #12) reviewed for accidents, the facility did not ensure that a resident's care plan was revised with new interventions following a fall. Specifically Resident #12 had 7 falls from 9/16/23 to 5/3/24 and care plans were not revised to reflect the recommendations made on accident reports or rehab recommendations.

Inspectors wroteBased on record review observation and interview conducted during the recertification survey it was determined for 2 of 3 residents reviewed for quality of care (Resident #10 and #2), the facility did not ensure residents received treatment and care in accordance with professional standards of quality. Specifically, 1. Resident #10 had a fall on 4/14/24 which resulted in a nondisplaced transverse fracture of the distal malleolus and the facility did not ensure that a CAM boot (orthopedic device that limits foot movement and protects the area during recovery) and/or physical therapy were provided in a timely manner as per orthopedic recommendation and 2. Resident #22 with diagnoses including end stage renal disease had pruiritis(itchy skin) which resulted in visible excoriation/s (breaks in the skin) and the physician was not notified resulting in a delay of treatment.

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 6/25/2024 to 7/2/2024, the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice. Specifically, the medication storage room was observed with expired medical equipment that was used to administer medications.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not provide food and drink that was at a safe and appetizing temperature for 3 of 5 food items (shrimp salad, cucumber salad, baked chicken/fish was the alternate, and apricots) being served from a steam table during the dining experience. Specifically, the baked chicken, shrimp salad and apricots were registered temperatures ranges in the danger zone (temperatures above 41 degrees Fahrenheit (F) and below 135 degrees (F), and that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not electronically transmit encoded and completed Minimum Data Set; a federally-mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) to the Centers for Medicare and Medicaid Services system information within 14 days of the final Minimum Data Set Assessment completion date as required for payment information and quality measure purposes. This was evident for 2 of 2 residents (#16 and #18) reviewed for resident assessment.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey and Abbreviated Survey NY00271654) from 11/8/2022-11/14/2022 for 1 of 2 residents (Resident #17) reviewed for elopement, the facility did not ensure all residents received adequate supervision and devices to prevent accidents. Specifically, the wanderguard system did not operate as designed to prevent Resident #17 with exit seeking behaviors from exiting the building during an ice storm.

Inspectors wroteBased on observation, interview, and record review conducted during a Recertification Survey conducted between 11/8/12 to 11/14/22, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, during the kitchen tour the facility's main kitchen was observed to have outdated condiments in the refrigerator, spices with no legible open date, and spices labeled with open dates that did not follow the recommended storage guidelines.

Inspectors wroteBased on observation, interview, and record review conducted during a Recertification Survey conducted from 11/8/22 to 11/14/22, the facility did not consider the views of the resident council and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Specifically, the facility did not ensure resident council meetings were held between 3/24/21 to 10/28/22. Members of resident council voiced concerns regarding meetings not being held or how often meetings are supposed to take place. Members were also not aware of the grievance process to address concerns.