Garden Spot Village
GARDEN SPOT VILLAGE in NEW HOLLAND, PA — inspection on November 13, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
lateral foot was not treated from October 6, 2025, till October 8, 2025.
The wound was treated with Medihoney (dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) on October 8, 2025, two days after it was initially identified on October 6, 2025.Further review of the Progress Notes revealed a Secure Conversation dated October 9, 2025, at 2:26 p.m., indicating the resident with worsening abrasion on the left lateral foot with increasing redness and warmth to the dorsal foot.
The wound base is now with 50% yellow/tan slough tissue with hypergranulation (excessive growth of red granulation tissue that sits above the wound's skin level, usually caused by excessive moisture, infection, or irritation) on the dorsal edge of the wound.
The resident reports less tenderness to the area, but the area appears more inflamed (reddened, warm, and swollen), and drainage has also increased to moderate to heavy serous (clear).
The wound treatment was changed to Silver Alginate (dressing used for moderate to heavy exuding wounds to help control infection and promote a wound environment for healing).
Review of the Nurse Practitioner (NP) notes revealed an entry dated October 10, 2025, indicating the resident had an abrasion on the left foot that occurred when the foot rubbed on the footboard of the bed, as stated by the resident.
Staff noted that the area was extremely erythematous (abnormal redness of the skin due to accumulation of blood in the area) yesterday, with concerns over possible infection.
Today, the erythema of the foot has improved, but still very tender to touch.
The resident was diagnosed with left foot cellulitis (skin infection that causes a red, painful, and swollen area of skin, which is commonly caused by Staphylococcus bacteria that enter the body through a cut or break in the skin).
The wound care treatment was changed, and Doxycycline (an antibiotic) by mouth was ordered by the NP.Interview with licensed nurse Employee E2 on November 13, 2025, at 12:40 p.m., revealed the facility utilizes a kind of heel boot that covers the entire foot of the resident.
Employee E2 was unable to provide documented evidence the facility consistently implemented the heel boot intervention to protect Resident CL1's feet from developing further skin impairment.An interview with the NHA (Nursing Home Administrator) on November 13, 2025, at 2:00 p.m., was conducted.
The NHA confirmed there was no documented evidence the heel boot intervention to protect Resident CL1's feet from further skin impairment were implemented.
The NHA also confirmed a wound treatment on Resident CL1's left lateral foot was not completed on October 6, 2025, and October 7, 2025.
The facility failed to implement Resident CL1's heel boot intervention to prevent further skin impairment and failed to provide wound care to a wound abrasion, which resulted in actual harm when the wound deteriorated and became infected. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 1/5/24 28 Pa Code 211.5(f) Clinical RecordsPreviously cited 1/5/24
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