Edenbrook Of Yeadon

F-F689.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa Code 201.18(b)(1) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 395374 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395374 B. Wing 03/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Edenbrook of Yeadon Lansdowne and Lincoln Ave Yeadon, PA 19050

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 39344 potential for actual harm Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was Residents Affected - Some determined that the facility failed to maintain an effective infection control program related to Enhanced Barrier Precautions for three of three residents with sacral wounds observed (Residents Resident R1, Resident R2 and Resident R3).

Findings include:

Review of facility policy, Enhanced Barrier Precautions dated March 6, 2024, revealed, It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organisms (MDRO) such as a resident with chronic wounds requiring

a dressing, indwelling medical devices or residents with 'infection or colonization with an MDRO'. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Continued review revealed, High-Contact Resident Care Activities include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; wound care: any skin opening requiring a dressing. EBP are used in conjunction with standard precautions and expand

the use of PPE [Personal Protective Equipment] to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Further review revealed, Post clear signage on the door/wall outside resident room.

Review of Resident Resident R1's care plan, dated initiated December 9, 2021, revealed that the resident had a stage IV pressure ulcer (most severe stage of a pressure sore, wound extends deep into muscle, tendon or bone) to her sacrum. Continued review revealed another care plan, dated initiated April 9, 2024, for Enhanced Barrier Precautions related to the open wound on the resident's sacrum.

Observation on March 5, 2025, at 9:38 a.m. revealed Employee E4, licensed nurse, provide wound care to Resident Resident R1's sacrum, which included removing the old dressing, cleansing the wound and application of a new dressing. Employee E3, unit manager, provided assistance to Employee E4, licensed nurse, while the wound care was being performed. Both employees were observed wearing only gloves while providing care.

Review of Resident Resident R2's care plan, dated initiated February 5, 2025, revealed that the resident had a pressure wound. Continued review revealed another care plan, dated initiated March 5, 2025, for Enhanced Barrier Precautions related to the resident's sacral wound.

Observation on March 5, 2025, at 10:07 a.m. revealed Employee E5, licensed nurse, provide wound care to Resident Resident R2's sacrum, which included removing the old dressing, cleansing the wound and application of a new dressing. Employee E3, unit manager, provided assistance to Employee E5, licensed nurse, while the wound care was being performed. Both employees were observed wearing only gloves while providing care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 395374 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395374 B. Wing 03/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Edenbrook of Yeadon Lansdowne and Lincoln Ave Yeadon, PA 19050

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident Resident R3's care plan, dated initiated April 4, 2024, revealed that the resident had a stage IV pressure ulcer to her sacrum. Continued review revealed another care plan, dated initiated April 9, 2024, for Level of Harm - Minimal harm or Enhanced Barrier Precautions. potential for actual harm

Observation on March 5, 2025, at 10:01 a.m. revealed Employee E5, licensed nurse, turned Resident Resident R3 on Residents Affected - Some her side to assess her sacral wound dressing. Employee E3, unit manager, then provided assistance to Employee E5, licensed nurse, to reposition Resident Resident R3 in bed. Both employees were observed wearing only gloves while providing care.

Continued observation of the doors and walls for Residents Resident R1, Resident R2 and Resident R3 revealed that there was no signage posted to indicate that the residents required Enhanced Barrier Precautions.

Interview on March 5, 2025, at 10:15 a.m. Employee E3, unit manager, confirmed that Enhanced Barrier Precautions were not maintained while care was being provided by nursing staff to Residents Resident R1, Resident R2 and Resident R3. Employee E3, unit manager, also confirmed that there was no signage posted to indicate that the residents required Enhanced Barrier Precautions.

28 Pa Code 211.10(d) Resident care policies

28 Pa Code 211.12(d)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 395374