Cycle 1
Health 2024-07-02 · Fire 2024-07-02
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Goshen, NY
Glen Arden Inc
2-star overall rating with 1-star inspections with $108,046 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
214 Harriman Drive, Goshen, NY
(845) 291-7800
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-11-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.15
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.37
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.90
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
5.27
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,533
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0110
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.43
Baseline 18.88% · Performance 17.52% · Measure score 8.43 · Achievement 8.43 · Improvement 6.83
Healthcare-associated infections
5.66
Baseline 7.00% · Performance 6.14% · Measure score 5.66 · Achievement 5.66 · Improvement 3.78
Total nurse turnover
4.51
Baseline 43.75% · Performance 45.24% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Adjusted total nurse staffing
3.77
Baseline 4.93 hours · Performance 4.15 hours · Measure score 3.77 · Achievement 3.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 11.34% · Lower 95% interval 7.71% |
| Discharge to community | 48.52% |
50.57%
2 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 44.33% · Lower 95% interval 39.28% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.44% |
95.27%
3.2 pts better
|
Numerator 63 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 48.08% |
53.69%
5.6 pts worse
|
Numerator 25 · Denominator 52 |
| Discharge mobility score | 28.85% |
50.94%
22.1 pts worse
|
Numerator 15 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 64 · Adjusted rate 3.77% |
| Healthcare-associated infections requiring hospitalization | 6.14% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 3.03% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 73 |
| Staff flu vaccination coverage | 36.99% |
42%
5 pts worse
|
Numerator 27 · Denominator 73 |
| Discharge function score | 36.54% |
56.45%
19.9 pts worse
|
Numerator 19 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 94.12% |
96.28%
2.2 pts worse
|
Numerator 32 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 15.79% |
25.2%
9.4 pts worse
|
Numerator 6 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.7
1.3 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
91.2%
6.3 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 96.7% · Q3 100.0% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.0%
3.8 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.7% · Q3 6.5% · Q4 6.5% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
18.5%
16.6 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.1%
1.2 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 6.9% · Q4 13.8% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
13.5%
6.5 pts worse
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 21.4% · Q3 20.0% · Q4 19.4% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
14.8%
2.5 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.8% · Q4 23.8% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.9% |
15.1%
24.8 pts worse
|
16.3%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.9% |
15.5%
18.4 pts worse
|
14.9%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 25.0% · Q3 30.0% · Q4 41.9% · 4Q avg 33.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.9% |
0.6%
6.3 pts worse
|
1.0%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 9.3% · Q3 8.5% · Q4 5.4% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.2% |
1.4%
4.8 pts worse
|
1.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.1% · Q3 10.0% · Q4 3.4% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 40.1% |
20.8%
19.3 pts worse
|
19.8%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 34.7% · Q3 44.1% · Q4 36.2% · 4Q avg 40.1% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
6.9%
1.4 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.0% · Q3 7.4% · Q4 14.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
76.7%
26.7 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.5% · Q2 38.5% · Q3 56.7% · Q4 76.0% · 4Q avg 50.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
9.7%
1.2 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 7.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.4% |
78.8%
22.4 pts worse
|
79.7%
23.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
20.6%
4.3 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.4% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-14 · Fire 2022-11-14
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-09-14 · Fire 2020-09-14
5 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-02
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-07-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-27
D · Potential for more than minimal harm
2020-09-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-10-13
C · Minimal harm
2020-09-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-10-13
C · Minimal harm
2020-09-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2020-10-13
Inspection history
Recent health citations
G · Actual harm
2024-07-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-12
E · Potential for more than minimal harm
2024-07-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-12
E · Potential for more than minimal harm
2024-07-02
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2024-10-12
E · Potential for more than minimal harm
2024-07-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-12
D · Potential for more than minimal harm
2024-07-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
B · Minimal harm
2024-07-02
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-08-31
D · Potential for more than minimal harm
2022-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-31
B · Minimal harm
2022-11-14
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-12-31
E · Potential for more than minimal harm
2020-09-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-11-13
D · Potential for more than minimal harm
2020-09-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-11-13
D · Potential for more than minimal harm
2020-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-11-13
D · Potential for more than minimal harm
2020-09-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-11-13
D · Potential for more than minimal harm
2020-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-11-13
Penalties and ownership
What sits behind the stars
$108,046
2024-07-02
Fine
Fine · fine $108,046
Fine
$0
2024-07-02
Payment Denial
Payment Denial · denial start 2024-10-02 · 10 days
10 day denial
Ownership
Alexander, Jennifer
W-2 Managing Employee · Individual
Goldstein, Beth
Corporate Officer · Individual
Markopoulos, Anastasios
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Sapphire Nursing And Rehab At Goshen
Goshen, NY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Valley View Center For Nursing Care And Rehab
Goshen, NY
2-star overall rating with 1-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Campbell Hall Rehabilitation Center Inc
Campbell Hall, NY
1-star overall rating with 1-star inspections with Special Focus status with $245,508 in total fines with 40 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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