Cycle 1
Health 2026-01-09 · Fire 2026-01-09
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
New Holland, PA
Garden Spot Village
5-star overall rating with 4-star inspections with $8,018 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
433 S Kinzer Avenue, New Holland, PA
(717) 355-6247
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
73
Certified beds
Average residents
66
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-10-19
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
1.13
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.91
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.22
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.31
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.39
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.15
CMS adjusted RN staffing hours
Adjusted total hours
5.29
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
894
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0173
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.72
Baseline 17.73% · Performance 18.32% · Measure score 6.72 · Achievement 6.72 · Improvement 0
Healthcare-associated infections
5.60
Baseline 5.31% · Performance 6.16% · Measure score 5.60 · Achievement 5.60 · Improvement 0
Total nurse turnover
6.51
Baseline 35.71% · Performance 37.08% · Measure score 6.51 · Achievement 6.51 · Improvement 0
Adjusted total nurse staffing
6.14
Baseline 4.92 hours · Performance 4.82 hours · Measure score 6.14 · Achievement 6.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.42% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 5.34% · Lower 95% interval 6.53% |
| Discharge to community | 48.92% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 47.01% · Lower 95% interval 41.33% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 75 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 24 · Denominator 60 |
| Discharge mobility score | 48.33% |
50.94%
2.6 pts worse
|
Numerator 29 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.15% |
| Healthcare-associated infections requiring hospitalization | 6.16% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 2.99% · Lower 95% interval 2.86% |
| Staff COVID-19 vaccination coverage | 2.61% |
8.2%
5.6 pts worse
|
Numerator 6 · Denominator 230 |
| Staff flu vaccination coverage | 65.35% |
42%
23.3 pts better
|
Numerator 232 · Denominator 355 |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 33 · Denominator 60 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 67.39% |
25.2%
42.2 pts better
|
Numerator 31 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
93.5%
3.5 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.8% · Q3 3.4% · Q4 1.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
6.5%
1.8 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.8% · Q3 5.8% · Q4 3.6% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.5%
0.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 8.7% · Q3 7.1% · Q4 2.3% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
19.9%
0.4 pts worse
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 17.4% · Q3 20.5% · Q4 18.2% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
18.7%
6.8 pts worse
|
16.7%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 22.2% · Q3 28.2% · Q4 23.5% · 4Q avg 25.5% · 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 | 20.3% |
19.6%
0.7 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 24.5% · Q4 3.7% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
18.3%
2 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 25.6% · Q3 13.2% · Q4 27.5% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 1.6% · Q4 1.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
1.7%
3.8 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 1.7% · Q3 5.4% · Q4 5.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.4% |
26.4%
9 pts worse
|
19.8%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 39.7% · Q3 32.7% · Q4 39.2% · 4Q avg 35.4% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.3%
0.7 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.1% · Q3 5.7% · Q4 6.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
68.9%
27.6 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.4% · Q3 95.7% · Q4 94.5% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
9.8%
4.8 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 4.3% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
68.7%
28 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
23.1%
5.4 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 12.9% · Expected 17.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-13 · Fire 2024-12-13
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2024-01-05 · Fire 2024-01-05
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-09
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Not marked corrected
E · Potential for more than minimal harm
2024-01-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-05
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-29
C · Minimal harm
2024-01-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-29
Inspection history
Recent health citations
G · Actual harm
2025-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-15
D · Potential for more than minimal harm
2024-12-13
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-01-31
G · Actual harm
2024-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-01
Penalties and ownership
What sits behind the stars
$8,018
2024-01-05
Fine
Fine · fine $8,018
Fine
Ownership
Garden Spot Communities
5% Or Greater Direct Ownership Interest · Organization
Aldrich, Donald
Corporate Director · Individual
Bender, Tim
Corporate Director · Individual
Edwards, Carl
Corporate Director · Individual
Garden Spot Communities
Operational/Managerial Control · Organization
Hess, Philip
Corporate Director · Individual
Hoover, Joyce
Corporate Director · Individual
Lindsey, Stephen
Operational/Managerial Control · Individual
Lindsey, Stephen
Corporate Officer · Individual
Musser, Karen
Corporate Director · Individual
Rittersbach, Elma
Corporate Director · Individual
Rouvre Haeusler, Christina
W-2 Managing Employee · Individual
Stoltzfus, Alphaus
Corporate Director · Individual
Vega, David
Corporate Director · Individual
Weber, Nathaniel
Operational/Managerial Control · Individual
Weber, Nathaniel
Corporate Officer · Individual
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#2
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#3
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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