Pennsylvania Department of Health
GARDENS AT YORK TERRACE, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT YORK TERRACE, THE
Inspection Results For:

There are  79 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GARDENS AT YORK TERRACE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on February 12, 2024, at The Gardens at York Terrace, it was determined that there were no federal deficiences identified under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care; however, the facility was not in compliance with the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for two of four days reviewed.

Findings include:

Review of nursing schedules for four days from February 8, 2024, through February 11, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day (7:00 a.m. to 3:00 p.m.) shift on February 10, and 11, 2024.




 Plan of Correction - To be completed: 02/22/2024

The facility cannot retroactively correct the CNA staffing ratio requirements; however, a review of each specific day will be completed.

The facility will have daily staffing meetings to review CNA staffing ratios. The facility will continue to hire and utilize agency staff for open shifts. The facility will implement the new staffing calculator template for CNA staffing ratios based on census. Education will be provided on the staffing components.

The facility to report findings from the calculator to QAPI for review and recommendations for 4 months

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for three of four days reviewed.

Findings include:

Review of nursing schedules for four days from February 8, 2024, through February 11, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day (7:00 a.m. to 3:00 p.m.) shift on February 10, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night (11:00 p.m. to 7:00 a.m.) shift on February 9, 10, and 11, 2024.


 Plan of Correction - To be completed: 02/22/2024

The facility cannot retroactively correct the LPN staffing ratio requirements; however, a review of each specific day will be completed.

The facility will have daily staffing meetings to review LPN staffing ratios. The facility will continue to hire and utilize agency staff for open shifts. The facility will implement the new staffing calculator template for LPN staffing ratios based on census. Education will be provided on the staffing components.

The facility to report findings from the calculator to QAPI for review and recommendations for 4 months.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port