Edenbrook of Yeadon: Infection Control Failures - PA
The violations involved three residents with sacral wounds, including two with stage IV pressure ulcers — the most severe type of bedsore that extends deep into muscle, tendon or bone. All three residents were supposed to receive Enhanced Barrier Precautions, which require staff to wear both gowns and gloves during wound care to prevent the spread of multidrug-resistant organisms.
Instead, licensed nurses and a unit manager provided wound care while wearing only gloves.
On March 5, inspectors watched Employee E4, a licensed nurse, remove an old dressing, cleanse a stage IV pressure ulcer on Resident R1's sacrum, and apply a new dressing. Employee E3, the unit manager, assisted with the procedure. Both staff members wore only gloves during the entire wound care process.
The same pattern repeated with two other residents within 30 minutes.
At 10:01 a.m., Employee E5, another licensed nurse, turned Resident R3 on her side to assess her sacral wound dressing. Employee E3, the unit manager, helped reposition the resident in bed. Again, both employees wore only gloves while providing care to a resident with a stage IV pressure ulcer.
Six minutes later, the same licensed nurse and unit manager provided wound care to Resident R2, who had a pressure wound on her sacrum. They removed the old dressing, cleaned the wound, and applied a new dressing — all while wearing only gloves.
The facility's own Enhanced Barrier Precautions policy, dated March 6, 2024, explicitly states that staff must wear gowns and gloves during "high-contact resident care activities" when caring for residents with chronic wounds requiring dressings. The policy defines wound care as "any skin opening requiring a dressing" and identifies it as a high-contact activity requiring enhanced protection.
Enhanced Barrier Precautions are designed to reduce transmission of multidrug-resistant organisms that can spread through contact with staff hands and clothing. The policy explains that these precautions "expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing."
Care plans confirmed all three residents required these enhanced protections. Resident R1's care plan for Enhanced Barrier Precautions was initiated April 9, 2024, specifically related to her open sacral wound. She had been dealing with the stage IV pressure ulcer since December 2021.
Resident R2's Enhanced Barrier Precautions care plan was created the same day inspectors arrived — March 5, 2025 — for her sacral wound. Her pressure wound care plan had been in place since February 5.
Resident R3 had both a stage IV pressure ulcer care plan from April 2024 and an Enhanced Barrier Precautions plan from the same month.
The facility also failed to post required signage outside the residents' rooms indicating Enhanced Barrier Precautions were needed. The policy specifically requires "clear signage on the door/wall outside resident room" to alert staff to the special infection control measures.
Inspectors found no such signs posted for any of the three residents.
When confronted, Employee E3, the unit manager who had participated in all three instances of improper wound care, acknowledged the violations. During an interview at 10:15 a.m., she confirmed that Enhanced Barrier Precautions were not maintained while nursing staff provided care to Residents R1, R2 and R3. She also confirmed there was no signage posted to indicate the residents required enhanced precautions.
The inspection was conducted in response to a complaint. Multidrug-resistant organisms pose particular risks in nursing home settings, where residents often have compromised immune systems and multiple medical conditions. Stage IV pressure ulcers represent the most serious type of bedsore, indicating tissue death that has progressed through all layers of skin and into underlying structures.
The facility's policy acknowledges that residents with indwelling medical devices, chronic wounds requiring dressings, or infection or colonization with multidrug-resistant organisms have "an increased risk for acquiring" dangerous bacteria. Enhanced Barrier Precautions are meant to interrupt that transmission pathway by preventing contamination of staff clothing and hands during direct patient care.
By skipping the required gowns, staff members potentially exposed themselves and other residents to whatever organisms might be present in the wound sites of three residents with serious, chronic injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edenbrook of Yeadon from 2025-03-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
EDENBROOK OF YEADON in YEADON, PA was cited for violations during a health inspection on March 5, 2025.
Instead, licensed nurses and a unit manager provided wound care while wearing only gloves.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.