Edenbrook Of Yeadon
EDENBROOK OF YEADON in YEADON, PA — inspection on March 5, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
28 Pa Code 205.63(b) Plumbing and piping systems required for existing and new construction
395374 03/05/2025
Edenbrook of Yeadon Lansdowne and Lincoln Ave Yeadon, PA 19050
that water temperatures should not exceed 110 degrees Fahrenheit, what to do if water temperatures
jeopardy to resident health or Unit at residents' hand sinks and in the Central Shower Room were tested and verified that they did safety not exceed 110 degrees Fahrenheit.
Maintenance and Supervisory staff were observed checking water temperatures and completing audit logs.
Water temperature logs were reviewed and revealed
Following verification of the implementation of the immediate action plan, review of water temperature logs and review of staff education documentation, the Immediate Jeopardy was lifted on March 5, 2025, at 5:20 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa Code 211.12(d)(5) Nursing services
395374 03/05/2025
Edenbrook of Yeadon Lansdowne and Lincoln Ave Yeadon, PA 19050
Observation conducted at the time of the interview, revealed the hot water temperature reading from the shower stall in the TCU Central Shower Room was 122.3 degrees Fahrenheit.
Further interview with Employee E10, nurse aide, revealed that she was assigned to work on the TCU Nursing Unit that shift.
Employee E10, nurse aide, stated that four residents in her assignment, Residents R7, R8, R6 and R9, were able to independently use the hand sinks in their rooms.
Interview on March 5, 2025, at 11:30 a.m. with Employee E11, nurse aide, revealed that she was assigned to work on the TCU Nursing Unit that shift.
Continued interview revealed Employee E11 was unable to state what the safe water temperature range should be when bathing a resident.
Further interview, Employee E11, nurse aide, stated that three residents in her assignment, Residents R10, R11 and R12, were able to independently use the hand sinks in their rooms.
Based on the deficiencies identified in this report, the NHA failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation.
Refer to F-F689. 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management
395374 03/05/2025
Edenbrook of Yeadon Lansdowne and Lincoln Ave Yeadon, PA 19050
R3 on her side to assess her sacral wound dressing.
Employee E3, unit manager, then provided
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 R1, R2 and 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
Review of 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 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 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 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.
395374
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.