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

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

There are  36 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:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 17, 2024, at The Gardens at York Terrace, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID #510202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that The Gardens at York Terrace had deficiencies that have the potential for minimal harm as related to the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected wood frame structure, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide smoke compartments not larger than 22,500 square feet, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on January 17, 2024, at 12:35 PM, revealed the first floor Zone 2 exceeded 22,500 square feet.

Interview at the time of the exit conference with with the Housekeeping Manager on January 17, 2024, at 12:35 PM, confirmed the square footage of Zone 2 exceeded 22,500 square feet.




 Plan of Correction - To be completed: 02/06/2024

Facility requests DSI to conduct a FSES survey.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #510202
Component 02
Lounge/Dayroom Building

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that The Gardens at York Terrace was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit doors to be free of obstructions, in one of four smoke zones within the component.

Findings include:

1. Observation on January 17, 2024, at 1:00 PM, revealed one of two exit access doors from the Dining/Activity Room was equipped with a manually-operated barrel bolt. This lock would not allow the emergency door to operate properly.

Interview with the Housekeeping Manager on January 17, 2024, at 1:00 PM, confirmed the door had barrel bolt installed.



 Plan of Correction - To be completed: 02/06/2024

The facility to remove the manually operated barrel bolt and temporary sign for emergency exit.

The facility to audit all emergency exits to ensure free of obstructions for egress.

Education provided to department managers on emergency exits. An audit of emergency exits to be audited monthly and submitted to QAPI for 4 months by maintenance designee.


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