Cycle 1
Health 2024-07-16 · Fire 2024-07-16
10 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cicero, NY
The Cottages At Garden Grove, A Skilled Nrsg Comm
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5460 Meltzer Court, Cicero, NY
(315) 699-1619
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
156
Certified beds
Average residents
138
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.99
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.50
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,962
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.72% · Performance 23.12% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.55
Baseline 5.63% · Performance 7.67% · Measure score 0.55 · Achievement 0.55 · Improvement 0
Total nurse turnover
5.91
Baseline 49.73% · Performance 39.51% · Measure score 5.91 · Achievement 5.91 · Improvement 3.61
Adjusted total nurse staffing
4.84
Baseline 5.27 hours · Performance 4.45 hours · Measure score 4.84 · Achievement 4.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.08% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 349 · Observed rate 9.74% · Lower 95% interval 8.7% |
| Discharge to community | 51.87% |
50.57%
1.3 pts better
|
No Different than the National Rate · Eligible stays 411 · Observed rate 46.72% · Lower 95% interval 47.3% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.95% |
95.27%
3.7 pts better
|
Numerator 283 · Denominator 286 |
| Falls with major injury | 2.1% |
0.77%
1.3 pts worse
|
Numerator 6 · Denominator 286 |
| Discharge self-care score | 59.6% |
53.69%
5.9 pts better
|
Numerator 118 · Denominator 198 |
| Discharge mobility score | 70.71% |
50.94%
19.8 pts better
|
Numerator 140 · Denominator 198 |
| Pressure ulcers or injuries, new or worsened | 3.15% |
2.29%
0.9 pts worse
|
Numerator 9 · Denominator 286 · Adjusted rate 3.73% |
| Healthcare-associated infections requiring hospitalization | 7.67% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 260 · Observed rate 7.31% · Lower 95% interval 5.26% |
| Staff COVID-19 vaccination coverage | 3.24% |
8.2%
5 pts worse
|
Numerator 6 · Denominator 185 |
| Staff flu vaccination coverage | 57.23% |
42%
15.2 pts better
|
Numerator 95 · Denominator 166 |
| Discharge function score | 62.12% |
56.45%
5.7 pts better
|
Numerator 123 · Denominator 198 |
| Transfer of health information to provider | 98.68% |
95.95%
2.7 pts better
|
Numerator 75 · Denominator 76 |
| Transfer of health information to patient | 92.95% |
96.28%
3.3 pts worse
|
Numerator 145 · Denominator 156 |
| Resident COVID-19 vaccinations up to date | 40.27% |
25.2%
15.1 pts better
|
Numerator 60 · Denominator 149 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.5% |
91.2%
15.7 pts worse
|
93.4%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 66.3% · Q3 78.8% · Q4 86.4% · 4Q avg 75.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.9% |
95.3%
3.4 pts worse
|
95.5%
3.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| 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 6.6% · Q2 7.1% · Q3 4.8% · Q4 9.1% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
18.5%
14.8 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 8.9% · Q4 4.7% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
6.1%
1.4 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.4% · Q3 8.3% · Q4 9.5% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
13.5%
7.7 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 17.3% · Q3 21.2% · Q4 21.6% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
14.8%
0.5 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 16.9% · Q3 12.7% · Q4 11.3% · 4Q avg 15.3% · 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 | 29.6% |
15.1%
14.5 pts worse
|
16.3%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 30.4% · Q3 24.8% · Q4 32.8% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.5% |
15.5%
17 pts worse
|
14.9%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 33.3% · Q3 33.3% · Q4 32.1% · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.6%
1.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.0% · Q3 2.1% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
1.4%
5.1 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.2% · Q3 6.9% · Q4 4.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.5% |
20.8%
8.7 pts worse
|
19.8%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 31.0% · Q3 28.0% · Q4 22.5% · 4Q avg 29.5% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
6.9%
0.4 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 8.3% · Q3 9.5% · Q4 7.7% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.2% |
76.7%
20.5 pts worse
|
81.7%
25.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 53.7% · Q3 63.9% · Q4 77.2% · 4Q avg 56.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
9.7%
1.2 pts worse
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.1% |
78.8%
0.7 pts worse
|
79.7%
1.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
20.6%
8.9 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 26.1% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-10 · Fire 2022-06-10
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-11-05 · Fire 2019-11-05
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
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 2024-09-04
D · Potential for more than minimal harm
2024-07-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-04
F · Potential for more than minimal harm
2022-06-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-10
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 2022-07-22
D · Potential for more than minimal harm
2019-11-05
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2019-11-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-04-01
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-01
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 2025-05-19
D · Potential for more than minimal harm
2024-07-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-19
D · Potential for more than minimal harm
2023-06-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-08
E · Potential for more than minimal harm
2022-06-10
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 2022-07-22
E · Potential for more than minimal harm
2022-06-10
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 2022-07-22
E · Potential for more than minimal harm
2022-06-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-10
F696 · Quality of Life and Care Deficiencies
Health
Provide appropriate care/assistance for a resident with a prosthesis.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-07-22
D · Potential for more than minimal harm
2019-11-05
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-05
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 2019-12-20
D · Potential for more than minimal harm
2019-11-05
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 2019-12-20
Penalties and ownership
What sits behind the stars
Ownership
Bergemann, John
Corporate Director · Individual
Drapola, Barbara
Corporate Director · Individual
Hefferon, Penny
Corporate Officer · Individual
Kelly, Donna
Corporate Director · Individual
Murray, John
Contracted Managing Employee · Individual
Stanford, Christine
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Elderwood At Liverpool
Liverpool, NY
2-star overall rating with 3-star inspections with $56,921 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Sunnyside Care Center
East Syracuse, NY
2-star overall rating with 2-star inspections with $12,155 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Bishop Rehabilitation And Nursing Center
Syracuse, NY
1-star overall rating with 1-star inspections with $699,602 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Jump out