Garden Spot Village
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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GARDEN SPOT VILLAGE in NEW HOLLAND, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NEW HOLLAND, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GARDEN SPOT VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.