The Cottages at Garden Grove, A Skilled NRSG Comm

In the surveyor’s words

From the most serious findings on record at The Cottages at Garden Grove, A Skilled NRSG Comm, in the surveyor’s own words.

• Actual harm, isolatedF686May 1, 2026

  Based on record review and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one of five residents (Resident #153) reviewed. Specifically, Resident #153 developed a Stage 2 pressure ulcer (partial thickness tissue loss) to the coccyx (tailbone) and there was no documented evidence that wound care orders were clarified to determine if the treatment was daily or every three days; and there was no documented evidence of regular pressure ulcer assessments between [DATE] and [DATE]. […]

• No harm, potential for more than minimal, patternF880May 1, 2026

  Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of three (3) residents (Resident #35) and one (1) of 12 Cottages (Cottage 31) reviewed. Specifically, staff in Cottage 31 did not change their gloves or perform hand hygiene in between cleaning resident rooms; and Resident #35's urinary drainage tubing was laying directly on the floor. […]

• No harm, potential for more than minimal, patternF610May 2, 2024

  Based on record review and interview conducted during the abbreviated survey (NY00329594 and NY00331170), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 2 of 3 residents (Resident #1 and 2) reviewed. Specifically, - Resident #1 was found with a bruise of unknown origin and an assessment was not completed timely, and an investigation to rule out abuse/neglect was not initiated at the time of the report. - Resident #1 fell and sustained an injury and the investigation did not identify if the resident's care plan was followed for toileting (every 2 to 4 hours) or if the resident's fall mat was in place at the time of the fall. -Resident #2 had a fall and it was documented they were clearly incontinent. […]

• No harm, potential for more than minimal, patternF550Jun 10, 2022

  Based on observation, interview, and record review during the recertification survey conducted 6/7/22-6/10/22, the facility failed to ensure each resident had the right to a dignified existence for 12 of 19 residents (Residents # 6, 13, 28, 34, 43, 47, 60, 66, 69, 77, 84, and 96) reviewed. Specifically, Resident #43 was observed with an unclean wheelchair; Residents #66 and 69 waited for their meals for extended periods of time after their tablemates were served and eating: and Residents #6, 13, 28, 34, 43, 47, 60, 66, 69, 77, 84, and 96 were served their breakfast meals over an hour after the scheduled meal service time. […]

• No harm, potential for more than minimal, patternF584Jun 10, 2022

  Based on observation and interview during the recertification and abbreviated (NY 492) surveys conducted 6/7/22-6/10/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 8 of 9 cottages (Cottages #11, #21, #31, #50, #51, #60, #77, and #87) reviewed. Specifically, Cottages #11, 21, 31, 50, 51, 60, 77 and 87 were observed with stained chairs and multiple areas in need of repair, and Cottage #77 had leaking water from the kitchen to the dining room from the dishwasher and 3 bay sink. Findings include: LEAKING DISHWASHER AND THREE BAY SINK During an observation in cottage #77 on 6/7/22 at 12:25 PM, the bottom of the half wall in the dining room had plastic molding leaning against a wall with missing and rotted drywall. […]