Garden Spot Village

In the surveyor’s words

From the most serious findings on record at Garden Spot Village, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 13, 2025

  Based on clinical records review and staff interviews, it was determined the facility failed to implement an intervention to prevent a wound on the foot of a resident identified as high risk for skin impairment. The facility also failed to initiate a wound treatment, which resulted in actual harm of the wound worsening and getting infected for one of the two residents reviewed (Resident CL1).Findings include: Review of Resident CL1's demographic sheet revealed the resident was admitted to the facility on [DATE], post amputation of the right foot toe. […]

• Actual harm, isolatedF684Jan 5, 2024

  Based on review of facility policy and clinical record review, it was determined that the facility failed to follow physician's orders and timely notify the physician of a significant change in condition for one of 18 residents reviewed, resulting in actual harm of Hypoxia (the body is deprived of adequate oxygen supply at the tissue level) for Resident 8. Findings include: Review of facility policy, Notification of Condition Changes, last revised April 19, 2023, revealed the facility would notify the resident's provider when there is a significant change in the resident's condition, abnormal test results, and/or a need to alter treatment significantly. […]

• No harm, potential for more than minimal, isolatedF947Dec 13, 2024

  Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12-hour annual re-training for one of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed four nurse aides received the required 12-hour annual retraining. Further review of the staffing records and inservice documentation revealed one of the five records reviewed failed to reveal evidence of 12-hour annual retraining. Interview with the Nursing Home Administrator on December 13, 2024, at 10:00 a.m. confirmed one nurse aide did not complete the required 12-hour annual retraining within the appropriate timeframe. 28 Pa. Code 201.20(a)(c) Staff Development

• No harm, potential for more than minimal, isolatedF641Jan 5, 2024

  Based on clinical record review and staff interview it was determined the facility failed to complete accurate assessments for one of 24 residents reviewed. (Resident 70) Findings Include: Review of Resident 70's clinical record inclusding progress notes revealed a nursing entry dated October 27, 2023 indicating Resident 70 went home with all of his belongings and medications. Review of Resident 70's discharge Minimum Data Set (MDS- periodic assessment of resident needs) dated October 27, 2023 revealed the assessment was coded as Resident 70 being discharged to a hospital. Interview with Licensed Nursing Employee E3 on January 5, 2023 at 10:00 a.m. […]