Inspection Reports for
The Cottages at Garden Grove, A Skilled Nursing Community
5460 Meltzer Court, Cicero, NY, 13039
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 19, 2025
Visit Reason
The abbreviated survey was conducted to evaluate compliance with professional standards of care, specifically regarding treatment and care related to bowel management for residents.
Findings
The facility failed to ensure timely treatment and interventions for a resident who did not have bowel movements for more than three days. The medical provider was not notified of the resident's bowel status or when bowel medication was unavailable, and the facility's bowel movement documentation and protocol were outdated and inconsistently followed.
Deficiencies (1)
F 0684: The facility did not provide appropriate treatment and care according to orders and resident preferences. Resident #1 did not receive timely bowel interventions despite no bowel movements for multiple days, and the medical provider was not notified when bowel medications were not administered or when the resident's condition worsened.
Report Facts
Days without bowel movement: 7
Days without bowel movement: 9
Medication administration gap: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Documented resident's bowel status and medication administration; involved in bowel interventions. |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Documented resident's condition, hospital transfer, and post-hospital care; interviewed regarding bowel management. |
| Assistant Director of Nursing #7 | Assistant Director of Nursing | Acknowledged outdated bowel movement protocol and ongoing revision; interviewed about documentation issues. |
| Nurse Practitioner #8 | Nurse Practitioner | Expected notification of bowel interventions and outcomes; interviewed regarding clinical expectations. |
| Registered Nurse #10 | Registered Nurse | Documented resident's bowel status and interventions during the survey period. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Apr 1, 2025
Visit Reason
Two standard health citations related to accident hazards and self-determination were cited and corrected.
Findings
Two standard health citations related to accident hazards and self-determination were cited and corrected.
Deficiencies (2)
Free of accident hazards/supervision/devices
Self-determination
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Apr 1, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with resident rights and care standards, including investigation of specific incidents involving resident care refusals and supervision during care.
Findings
The facility failed to promote and facilitate resident self-determination for one resident who refused incontinence care but was provided care anyway. Additionally, the facility did not ensure adequate supervision for another resident requiring two staff during care, resulting in skin tears and an undetermined fracture.
Deficiencies (2)
F 0561: The facility did not promote and facilitate resident self-determination through support of resident choice. Resident #1 refused incontinence care but staff continued to provide care following multiple refusals.
F 0689: The facility did not ensure adequate supervision and assistance devices to prevent accidents for Resident #2. The resident was care planned for two staff but was provided care alone, resulting in skin tears and an undetermined fracture.
Report Facts
Residents affected: 1
Residents affected: 1
Deficiency tags cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #4 | Certified Nurse Aide | Named in refusal of care incident involving Resident #1 |
| Certified Nurse Aide #9 | Certified Nurse Aide | Named in inadequate supervision and skin tear incident involving Resident #2 |
| Certified Nurse Aide #10 | Certified Nurse Aide | Assisted during care of Resident #2 and noted skin tears |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interviews and progress notes related to Resident #1 and Resident #2 incidents |
| Director of Social Services | Director of Social Services | Provided interview regarding resident rights education and incident follow-up |
| Director of Nursing | Director of Nursing | Provided interview regarding staff expectations and disciplinary actions |
| Nurse Practitioner #12 | Nurse Practitioner | Provided medical evaluation notes related to Resident #2's fracture |
| Nurse Practitioner #13 | Nurse Practitioner | Provided medical evaluation notes and interview regarding Resident #2's fracture |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 16, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 7/8/2024 to 7/16/2024 to assess compliance with regulatory requirements for a skilled nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure proper resident positioning and assistance with activities of daily living, inadequate personal hygiene care, lack of meaningful activities tailored to resident preferences, improper pressure ulcer care and prevention, serving food at inappropriate temperatures, and failure to maintain an effective infection prevention and control program.
Deficiencies (6)
F 0676: The facility did not ensure residents were given appropriate treatment and services to maintain or improve their ability to carry out activities of daily living. Resident #61 was observed leaning far to the right in their wheelchair without assistance for repositioning.
F 0677: The facility did not ensure residents unable to carry out activities of daily living received necessary services for nutrition, grooming, and hygiene. Resident #100 was not assisted with removing unwanted facial hair and had unclean, untrimmed fingernails.
F 0679: The facility did not provide an ongoing program to support residents' choice of activities meeting their interests and psychosocial well-being. Resident #120 was not offered meaningful activities aligned with their preferences.
F 0686: The facility did not ensure residents with pressure ulcers received necessary treatment and services to promote healing and prevent infection. Resident #125 lacked an alternating pressure overlay as ordered, and Resident #7's wound treatments were not completed as ordered.
F 0804: The facility did not ensure food and drink were served at palatable, flavorful, and safe temperatures. Hot foods were served below required temperatures and cold foods and drinks were served above required temperatures during observed meals.
F 0880: The facility failed to establish and maintain an infection prevention and control program. Licensed Practical Nurse #7 and Certified Nurse Aide #8 did not perform proper hand hygiene or wear gowns during wound and incontinence care for Resident #106 on enhanced barrier precautions.
Report Facts
Deficiencies cited: 6
Pressure ulcer measurements: 1.9
Pressure ulcer measurements: 1.5
Food temperature: 130
Food temperature: 58
Food temperature: 69
Food temperature: 52
Food temperature: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in infection prevention and control deficiency related to improper hand hygiene and wound care |
| Certified Nurse Aide #8 | Certified Nurse Aide | Named in infection prevention and control deficiency related to improper hand hygiene and wound care |
| Certified Nurse Aide #12 | Certified Nurse Aide | Mentioned in relation to resident positioning deficiency |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Mentioned in relation to resident positioning deficiency |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding resident positioning and pressure ulcer care |
| Occupational Therapist #15 | Occupational Therapist | Interviewed regarding resident positioning and wheelchair supports |
| Certified Nurse Aide #34 | Certified Nurse Aide | Mentioned in relation to personal hygiene deficiency |
| Certified Nurse Aide #37 | Certified Nurse Aide | Mentioned in relation to personal hygiene deficiency |
| Licensed Practical Nurse #29 | Licensed Practical Nurse | Mentioned in relation to personal hygiene and pressure ulcer care |
| Recreation Specialist #2 | Recreation Specialist | Interviewed regarding activity program deficiency |
| Director of Therapeutic Recreation | Director of Therapeutic Recreation | Interviewed regarding activity program deficiency |
| Licensed Practical Nurse #36 | Licensed Practical Nurse | Named in wound care treatment deficiency for Resident #7 |
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Interviewed regarding wound care treatment deficiency |
| Assistant Director of Nursing #21 | Assistant Director of Nursing | Interviewed regarding wound care and pressure ulcer care deficiencies |
| Infection Preventionist #46 | Infection Preventionist | Interviewed regarding infection control deficiencies |
| Food Service Director #23 | Food Service Director | Interviewed regarding food temperature deficiencies |
| Registered Dietitian #24 | Registered Dietitian | Interviewed regarding food temperature deficiencies |
| Registered Unit Nurse Manager #14 | Registered Unit Nurse Manager | Interviewed regarding infection control deficiencies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Jul 16, 2024
Visit Reason
Multiple standard health citations related to activities of daily living, infection control, nutrition, and investigation of alleged violations, plus life safety code citations for fire alarm, hazardous areas, and means of egress; all corrected.
Findings
Multiple standard health citations related to activities of daily living, infection control, nutrition, and investigation of alleged violations, plus life safety code citations for fire alarm, hazardous areas, and means of egress; all corrected.
Deficiencies (11)
Activities daily living (adls)/mntn abilities
Activities meet interest/needs each resident
ADL care provided for dependent residents
Infection prevention & control
Investigate/prevent/correct alleged violation
Nutritive value/appear, palatable/prefer temp
Responsibilities of providers; required notif
Treatment/svcs to prevent/heal pressure ulcer
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Means of egress - general
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jul 16, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 7/8/2024 to 7/16/2024 to assess compliance with regulatory requirements for The Cottages at Garden Grove, a skilled nursing community.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate and report alleged abuse, inadequate assistance with activities of daily living, insufficient provision of meaningful activities, improper pressure ulcer care, serving food at inappropriate temperatures, and failure to maintain an effective infection prevention and control program.
Deficiencies (7)
F 0610: The facility failed to ensure all allegations of abuse, neglect, and mistreatment were thoroughly investigated or reported to the New York State Department of Health for Resident #77. Certified Nurse Aide #1 caused a skin tear and was not immediately removed from resident care pending investigation.
F 0676: Resident #61 was not assisted with repositioning while leaning far to the right in their wheelchair, contrary to care plan and facility policy.
F 0677: Resident #100 was not assisted with removing unwanted facial hair and had unclean, untrimmed fingernails despite care plan interventions.
F 0679: Resident #120 was not offered meaningful activities that included their interests and preferences, such as classical music, socialization, and outdoor time.
F 0686: Resident #125 did not have the ordered alternating pressure overlay in place; it was found rolled up on the floor. Resident #7's wound treatments were not completed as ordered for three days due to lack of supplies.
F 0804: Food served to residents during lunch meals on 7/10/2024 and 7/15/2024 was not at palatable or safe temperatures; hot foods were below required temperatures and cold foods were above required temperatures.
F 0880: Licensed Practical Nurse #7 and Certified Nurse Aide #8 failed to perform proper hand hygiene and did not wear gowns when providing incontinence and wound care to Resident #106 on enhanced barrier precautions, risking infection transmission.
Report Facts
Deficiencies cited: 7
Temperature measurement: 130
Temperature measurement: 58
Temperature measurement: 69
Temperature measurement: 53
Temperature measurement: 52
Temperature measurement: 53
Pressure ulcer size: 1.9
Pressure ulcer size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in abuse allegation involving Resident #77 causing a skin tear | |
| Registered Nurse Supervisor #2 | Involved in incident report and investigation of abuse allegation for Resident #77 | |
| Director of Nursing | Responsible for investigation and reporting of abuse allegation for Resident #77 | |
| Certified Nurse Aide #12 | Interviewed regarding repositioning and assistance with Resident #61 | |
| Certified Nurse Aide #34 | Interviewed regarding personal hygiene care for Resident #100 and food service | |
| Licensed Practical Nurse #36 | Failed to complete wound treatment for Resident #7 due to lack of supplies | |
| Licensed Practical Nurse #7 | Failed to perform proper hand hygiene and glove changes during wound care for Resident #106 | |
| Certified Nurse Aide #8 | Failed to perform hand hygiene and wear gowns during care for Resident #106 on enhanced barrier precautions |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 2, 2024
Visit Reason
The abbreviated survey was conducted to review alleged violations involving mistreatment, neglect, or abuse of residents at the facility.
Findings
The facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 2 of 3 residents reviewed. Investigations did not adequately assess if care plans were followed, including toileting schedules and use of fall mats or sensor alarms.
Deficiencies (1)
F 0610: The facility did not thoroughly investigate alleged mistreatment, neglect, or abuse for Resident #1 and Resident #2. Investigations lacked timely assessments, staff interviews, and review of care plan adherence related to falls and bruises.
Report Facts
Date of survey completion: May 2, 2024
Number of residents reviewed: 3
Number of residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| registered nurse #15 | Supervisor | Named in investigation of Resident #1's bruise and fall |
| licensed practical nurse #19 | Named in investigation of Resident #1's bruise | |
| certified nurse aide #18 | Named in investigation of Resident #1's fall and bruise | |
| registered nurse #21 | Named in investigation of Resident #1's fall | |
| registered nurse #1 | Unit Manager | Named in investigation of Resident #1 and Resident #2 incidents |
| certified nurse aide #5 | Named in investigation of Resident #2 fall | |
| certified nurse aide #6 | Named in investigation of Resident #2 fall | |
| registered nurse #7 | Named in investigation of Resident #2 fall | |
| certified nurse aide #8 | Named in investigation of Resident #2 fall | |
| certified nurse aide #9 | Named in investigation of Resident #2 fall | |
| licensed practical nurse #11 | Named in investigation of Resident #2 fall | |
| Director of Nursing | Oversight of investigations and facility incident reporting |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 2, 2024
Visit Reason
One standard health citation for investigation/prevention/correction of alleged violation with pattern scope; corrected.
Findings
One standard health citation for investigation/prevention/correction of alleged violation with pattern scope; corrected.
Deficiencies (1)
Investigate/prevent/correct alleged violation
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with care standards following an unwitnessed fall of Resident #1 and to assess the adequacy of neurological checks and treatment provided.
Findings
The facility failed to ensure neurological checks were completed as required after Resident #1's unwitnessed fall. Documentation of neurological checks was missing despite policy requirements, and the resident experienced a significant decline and subsequent death.
Deficiencies (1)
F 0684: The facility did not complete neurological checks as required after Resident #1's unwitnessed fall, despite policy mandating checks every 2 to 4 hours for 48 hours. Documentation of these checks was absent, and the resident's condition deteriorated leading to death.
Report Facts
Residents affected: 1
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
One standard health citation for quality of care; corrected.
Findings
One standard health citation for quality of care; corrected.
Deficiencies (1)
Quality of care
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Jun 10, 2022
Visit Reason
Multiple standard health citations related to ADL care, infection control, nutrition, prostheses, resident allergies, resident rights, and environment; life safety citations for electrical equipment and hazardous areas; all corrected.
Findings
Multiple standard health citations related to ADL care, infection control, nutrition, prostheses, resident allergies, resident rights, and environment; life safety citations for electrical equipment and hazardous areas; all corrected.
Deficiencies (9)
ADL care provided for dependent residents
Infection prevention & control
Nutritive value/appear, palatable/prefer temp
Prostheses
Resident allergies, preferences, substitutes
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Electrical equipment - testing and maintenanc
Hazardous areas - enclosure
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 10, 2022
Visit Reason
Recertification and abbreviated surveys conducted from 6/7/22 to 6/10/22 to assess compliance with regulatory requirements for a skilled nursing community facility.
Findings
The facility failed to ensure residents' rights to dignified existence, timely meal service, safe and clean environment, proper personal care, prosthetic care, food safety, dietary accommodations, and infection control practices. Multiple deficiencies were observed including unclean wheelchairs, delayed meal service, environmental maintenance issues, inadequate shaving assistance, lack of prosthetic assistance, improper food temperature and substitutions, and poor hand hygiene during medication administration and meal service.
Deficiencies (7)
F 0550: The facility failed to ensure residents' right to a dignified existence, including unclean wheelchairs and delayed meal service for multiple residents.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment with issues such as leaking dishwasher and sink, stained furniture, damaged blinds, and unpainted door frames in multiple cottages.
F 0677: The facility failed to provide necessary assistance with shaving for Resident #51 as planned, resulting in poor personal hygiene.
F 0696: The facility failed to provide appropriate care and assistance for Resident #18 to don their prosthetic limb, resulting in decreased functional mobility.
F 0804: The facility failed to ensure food and drink were palatable, attractive, and maintained at safe temperatures during meal service observations.
F 0806: The facility failed to provide food accommodations for Resident #66's gluten sensitivity, including lack of approved substitutions and absence of gluten-free bread.
F 0880: The facility failed to maintain an infection prevention and control program, with inadequate hand hygiene observed during medication administration and meal service.
Report Facts
Residents affected: 12
Residents affected: 8
Residents affected: 1
Residents affected: 1
Meal trays tested: 2
Residents affected: 1
Licensed practical nurse observed: 1
Meal observations with hand hygiene issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #19 | Certified Nurse Aide | Named in wheelchair cleaning and meal service delay findings |
| RN Manager #20 | Registered Nurse Manager | Named in wheelchair cleaning, meal service delay, and dietary substitution findings |
| CNA #22 | Certified Nurse Aide | Named in meal service delay and dietary substitution findings |
| RD #21 | Registered Dietitian | Named in meal service timing and dietary substitution findings |
| LPN #7 | Licensed Practical Nurse | Named in hand hygiene deficiencies during medication administration |
| ADON | Assistant Director of Nursing | Named in hand hygiene deficiencies during meal service |
| Food Service Director | Named in food temperature and dietary substitution findings | |
| PT #14 | Physical Therapist | Named in prosthetic care findings |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 5, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for a skilled nursing community facility.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve a resident's grievance regarding missing personal property, inadequate provision of meaningful activities for residents, improper drug storage and labeling, and unsafe food handling and storage practices.
Deficiencies (4)
F 0585: The facility did not make prompt efforts to resolve a resident's grievance regarding missing personal property, including lack of investigation and staff interviews.
F 0679: The facility did not ensure all residents were provided meaningful activities designed to meet their interests and support their mental, physical, and psychosocial well-being.
F 0761: The facility did not maintain drug and biological storage and labeling in accordance with professional standards, including unlabeled influenza vaccine vial, expired medications, and improper narcotic storage.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled and expired food items and improper glove use by staff serving food.
Report Facts
Residents reviewed for activities: 6
Residents affected: 1
Residents affected: 2
Residents affected: 1
Cottages inspected for food safety: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #12 | Licensed Practical Nurse | Named in medication storage and labeling deficiencies including unlabeled medication and expired drugs. |
| RN Unit Manager #17 | Registered Nurse Unit Manager | Involved in grievance investigation and medication storage oversight. |
| Social Worker #18 | Social Worker | Involved in grievance investigation and communication with police. |
| Director of Nursing (DON) #14 | Director of Nursing | Oversight of medication storage policies and grievance follow-up. |
| CNA #1 | Certified Nurse Aide | Observed with improper glove use during food service. |
| Director of Therapeutic Recreation | Director of Therapeutic Recreation | Interviewed regarding lack of meaningful activities for residents. |
| Food Service Director | Food Service Director | Interviewed regarding food storage and safety practices. |
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