Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardens At York Terrace, The during CMS and state inspections, most recent first.
The facility failed to maintain and document its sprinkler system as per NFPA 25 standards. It lacked documentation for a 3-year full trip test, with the last test in June 2021, and did not have records of repairs to a deficient fire department connection identified in a recent inspection. Additionally, the sprinkler system was missing a hydraulic nameplate, affecting the system's functionality.
The facility failed to ensure that horizontal fire-rated doors in four smoke compartments were equipped to self-close and positively latch. Observations revealed that these doors required springs to function properly, affecting areas such as the Kitchen, Activity Room, and Rainbow Hall. The issue was confirmed by the Administrator and Director of Maintenance.
The facility failed to maintain the hazardous area doors within the allowed gap margins in one of the smoke zones. The Kitchen Storage Room door had a gap at the top exceeding the minimum allowed margin by 3/16-inch, confirmed during an interview with the Administrator and Director of Maintenance.
The facility failed to meet operational standards, with incomplete life safety drawings lacking essential details and missing documentation of annual testing for Carbon Monoxide Alarms. Additionally, the facility could not verify that alarms were audible to staff, as confirmed by the Administrator and Director of Maintenance.
The facility failed to provide documentation verifying the 4-year fire damper maintenance and exercise, as required by NFPA 101 standards for HVAC systems. This deficiency was confirmed during an exit conference with the Administrator and Director of Maintenance, who acknowledged the lack of documentation.
The facility failed to comply with NFPA 101 standards by not providing two remote exits in one of the smoke compartments, specifically in the partial basement. An observation revealed only a single means of egress, which was confirmed by the Administrator and Director of Maintenance.
The facility did not meet NFPA 101 standards for smoke compartment size, as Zone 2 on the 1st floor exceeded the maximum allowable 22,500 square feet. This was confirmed during an exit conference with the Administrator and Director of Maintenance.
A resident with osteoporosis and dementia experienced a significant weight loss, but the facility failed to notify the dietitian or assess the resident's nutritional status in a timely manner, as required by their policy. The weight loss was confirmed, but the dietitian was not involved until a later quarterly assessment, which was acknowledged by the Administrator.
Deficiencies in Sprinkler System Maintenance and Documentation
Penalty
Summary
The facility failed to meet the requirements for maintaining and testing its sprinkler system as per NFPA 25 standards. During a document review on December 18, 2024, it was found that the facility did not have documentation for the 3-year full trip test of the sprinkler system, with the last recorded test being in June 2021. This was confirmed during an interview with the Administrator and Director of Maintenance. Additionally, the facility lacked documentation for repairs to the fire department connection, which was identified as deficient during a 5-year internal inspection on November 20, 2024. The deficiency noted that the fire department connection could not pressurize the system due to deterioration. Furthermore, an observation and interview on the same day revealed that the sprinkler piping system was missing a hydraulic nameplate. This was also confirmed during the exit conference with the facility's Administrator and Director of Maintenance. These deficiencies indicate a failure to maintain critical components of the fire protection system, which affects the entire system's functionality.
Plan Of Correction
The facility reviewed sprinkler inspection reports to establish the last completed 3 year full trip test. The 3 year full trip test was completed on 5/10/2023 with the annual sprinkler inspection that year. This documentation is filed in the life safety survey book for review. The facility reviewed the deficiencies from the 5 year hydrostatic fire department connection testing inspection. This 5 year testing was completed on 11/20/24. The facility is developing a plan of action for the 5 year testing inspection cited summary. The facility is actively working with the sprinkler contractor and the local fire department to determine the best corrective action. In the interim, the facility will meet with the local fire chief to review the concerns from the testing for both awareness and planning, should the FDC be needed. The facility to request a TLW to address these concerns. The facility sprinkler system is a pipe system and will be labeled as a pipe system, by the sprinkler system vendor, by 2/04/2025. The facility will complete an audit of the sprinkler inspection reports from 2024 to ensure deficiencies have been addressed. The sprinkler inspections occurred on the following dates: 1/8/24 quarterly, 4/2/24 annual, 7/3/24 quarterly, 10/3/24 quarterly, and 1/6/25 quarterly. The annual sprinkler inspection for 2025 is anticipated completion by 4/30/2025. The reports will be filed in the facility life safety book. The facility is requesting a TLW for completion of the work that is needed for the FDC. Anticipated completion of this work would be 6/18/2025, as it is seasonal and greater external planning needed due to the location and correction of the FDC. Quarterly audits of the sprinkler reports will be completed by maintenance. Findings of the audits will be reported to QAPI for 9 months.
Failure to Maintain Self-Closing Fire Doors
Penalty
Summary
The facility failed to maintain the rated horizontal fire doors to self-close and positively latch within the frame in four of four smoke compartments. Observations made on December 18, 2024, between 12:05 PM and 12:30 PM, revealed that the horizontal fire-rated doors required springs to be attached to self-close and positively latch in the frame. The specific locations where this deficiency was observed include the 1st floor Kitchen Attic door, the 1st floor outside Kitchen Attic door, the 1st floor by the Activity Room Attic door, and the 1st floor Rainbow Hall by Resident Room 135 Attic door. During an interview at the exit conference with the Administrator and Director of Maintenance, it was confirmed that the horizontal fire-rated doors would not self-close and positively latch.
Plan Of Correction
The facility to inspect the attic doors noted as doors a, b, c, and d to render as non-rated to match the building rating assembly, consistent with the Type V (000) unprotected wood frame structure. The facility will audit all horizontal fire doors to ensure compliance to building structure. The facility to audit attic door compliance quarterly. The findings from the audits will be reported to QAPI for 3 months by maintenance staff.
Hazardous Area Door Gap Deficiency
Penalty
Summary
The facility failed to maintain the hazardous area doors within the allowed gap margins in one of the four smoke zones. Specifically, during an observation on December 18, 2024, at 12:10 PM, it was noted that the Kitchen Storage Room door had a gap at the top that exceeded the minimum allowed margin by 3/16-inch. This deficiency was confirmed during an interview at the exit conference with the Administrator and Director of Maintenance on the same day at 1:15 PM.
Plan Of Correction
The facility to correct the kitchen door by utilizing a door adjustor to meet the gap requirement. An audit of all hazardous doors will be audited to ensure compliance. The facility will complete a random audit of the hazardous doors quarterly. Education provided to maintenance staff regarding hazardous door requirements. The findings from the audits will be reported to QAPI for 6 months.
Deficiencies in Life Safety and Carbon Monoxide Alarm Protocols
Penalty
Summary
The facility failed to meet the minimum standards for operation as required by the Department and other state and local agencies. During a review of documentation and observation, it was found that the facility's life safety drawings were incomplete. Specifically, the drawings lacked essential details such as door swings, compartment labeling, fire wall boundaries, smoke wall boundaries, hazardous areas, width of zones, and travel distances. These omissions were confirmed during an exit conference with the Administrator and Director of Maintenance, indicating non-compliance with the requirements for a facility with an active Fire Safety Evaluation System (FSES). Additionally, the facility did not maintain documentation of annual testing and inspection of installed Carbon Monoxide Alarms as per the manufacturer's instructions, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. Furthermore, the facility could not verify that the installed carbon monoxide alarms were audible to on-duty staff. These deficiencies were confirmed during an exit conference with the Administrator and Director of Maintenance, highlighting a failure to adhere to safety protocols designed to protect the health and welfare of residents.
Plan Of Correction
The facility provided current layout and drawings that were to scale accounting for all information (including door swings, compartment labeling, fire wall boundaries, smoke wall boundaries, hazardous areas, width of zones and travel distances). The facility to install Carbon Monoxide detectors, in the required designated areas, with linking alarm devices in manned locations. The facility will audit all current detectors and remove devices in areas not needed. The facility to ensure preventative maintenance and auditing of the carbon monoxide devices, as per manufacturers guidance. The facility to provided education to maintenance on Act 48 PA Carbon Monoxide Requirements. Maintenance to report findings to QAPI for 3 months.
Failure to Document Fire Damper Maintenance
Penalty
Summary
The facility was found deficient in maintaining proper documentation for the 4-year fire damper maintenance and exercise, as required by NFPA 101 standards for HVAC systems. During a document review conducted on December 18, 2024, between 9:15 AM and 11:00 AM, it was revealed that the facility failed to provide evidence that the necessary fire damper maintenance and exercise had been performed. This deficiency was confirmed during an exit conference with the Administrator and Director of Maintenance, who acknowledged the lack of documentation for the required maintenance.
Plan Of Correction
The facility to complete a 4 year fire damper HVAC inspection, by the facility HVAC external service provider. This inspection is scheduled for 1/15/2025. The vendor will draft a report, including the fire damper and fusible link status. The facility maintenance staff will audit annually to ensure the fire damper documentation is available in the life safety survey book for reference. The facility maintenance staff will monitor for the next scheduled inspection, anticipated on or before, January 2029. Findings from the inspection to be reported to QAPI for 3 months.
Failure to Provide Two Remote Exits in Basement
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards for means of egress, specifically failing to provide two exits remote from one another in one of the four smoke compartments within the component. During an observation conducted on December 18, 2024, at 11:00 AM, it was noted that there was only a single means of egress from the partial basement. This deficiency was confirmed during an interview at the exit conference with the Administrator and Director of Maintenance later that day, where it was acknowledged that the basement lacked two acceptable exits.
Non-compliance with Smoke Compartment Size Requirements
Penalty
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments on the 1st floor, grade level, Zone 2. During an observation on December 18, 2024, it was found that this zone exceeded the maximum allowable size of 22,500 square feet for a smoke compartment. This deficiency was confirmed during an exit conference with the Administrator and Director of Maintenance, where it was acknowledged that the square footage of Zone 2 surpassed the specified limit.
Failure to Monitor and Assess Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess weight loss for a resident diagnosed with osteoporosis and dementia. The facility's policy required that any weight change of five pounds or more be retaken for confirmation, and if verified, the dietitian should be notified. The resident experienced a weight loss from 127 lbs. to 117 lbs. between March 1 and April 5, which was confirmed with a reweighing on April 7, showing a weight of 120 lbs. Despite this verified weight loss of 7 lbs. (5.5 percent), there was no evidence that the dietitian was notified or assessed the resident's nutritional status until April 30, during a regularly scheduled quarterly assessment. The Administrator confirmed the lack of notification to the dietitian, which was a deviation from the facility's policy.
Plan Of Correction
Resident 5 weights to be reviewed for accuracy. Resident 5 assessment to be completed by dietician. All resident weights and assessments to be reviewed for accuracy and timeliness for all current residents with a lookback review. Resident weights to be reviewed to ensure follow up completed according to the facility policy. A random monthly audit of weights to be completed by nursing administration or designee monthly. Education provided to licensed nursing staff and dietician regarding the weight policy. Findings from the audits will be reported to QAPI for 3 months.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pottsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Valley Skilled Nursing And Rehabilitation Ce | 0.2 mi | ★★★★★ | 11 | 0 |
| Edenbrook Of Greenwood Hill | 2.2 mi | ★★★★★ | 4 | 0 |
| Schuylkill Center | 2.8 mi | ★★★★★ | 16 | 0 |
| Rosewood Rehabilitation And Nursing Center | 4 mi | ★★★★★ | 1 | 0 |
| Seton Manor Nursing And Rehabilitation Center | 6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.