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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT YORK TERRACE, THE
Inspection Results For:

There are 96 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT YORK TERRACE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Revisit survey completed on February 11, 2026, regarding The Gardens at York Terrace, it was determined that the facility had not corrected the deficiencies cited during the survey of December 9, 2025, under the requirements of the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 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 7 through 10, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on the evening shift (3:00 p.m. to 11:00 p.m.) on February 7 and 8, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on the night shift (11:00 p.m. to 7:00 a.m.) on February 8, 2026.

Plan of Correction - To be completed: 04/06/2026

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

The facility will have staffing meetings to review CNA staffing ratios. The facility will hire for open positions, as available, and utilize agency staff for open shifts. The facility will have a regular meeting with the recruitment team to review candidate flow. The facility will utilize the staffing calculator template for staffing ratios based on census. Education will be provided on the staffing components to the nursing administrative team.

The facility to report staffing status to QAPI for review and recommendations for 4 months.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 times 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 7 through 10, 2026, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on the day shift (7:00 a.m. to 3:00 p.m.) on February 7 and 8, 2026.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on the night shift (11:00 p.m. to 7:00 a.m.) on February 7, 8, and 9, 2026.

Plan of Correction - To be completed: 04/06/2026

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

The facility will have staffing meetings to review LPN staffing ratios. The facility will hire for open positions, as available, and utilize agency staff for open shifts. The facility will have a regular meeting with the recruitment team to review candidate flow. The facility will utilize the staffing calculator template for staffing ratios based on census. Education will be provided on the staffing components to the nursing administrative team.

The facility to report staffing status to QAPI for review and recommendations for 4 months.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for two of four days reviewed.

Findings include:

Review of nursing schedules for four days from February 7 through 10, 2026, revealed the following total nursing care hours below minimum requirements:

February 7, 2026: 3.05 care hours per resident
February 8, 2026: 2.94 care hours per resident

Plan of Correction - To be completed: 04/06/2026

The facility cannot retroactively correct the hours for direct care requirements; however, a review of each specific day will be completed to ensure calculations are correct and all staff that can be counted are included.

The facility will have staffing meetings to review staffing hours per day. The facility will continue to hire and utilize agency, as available. The facility will utilize the staffing calculator template for monitoring. Education will be provided on the staffing components.

The facility to report staffing status to QAPI for 4 months.

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