Edenbrook of Yeadon

Inspectors wroteBased on clinical record review, facility policy, facility documentation, and staff interviews, it was determined the facility failed to ensure Resident R1 was free from abuse. Resident R1 was included in a social media post in which he was photographed from behind, partially exposing his buttocks and without a shirt. The image also contained profanity. A reasonable person in Resident R1's position would likely feel humiliated by having such a photograph taken and posted on social media without consent. Posting this image of a cognitively impaired Resident R1 caused harm. This deficiency was cited as past noncompliance. (Resident R1).

Inspectors wroteBased on Observations, review of clinical record, and interview with staff and residents, it was determined that the facility did not ensure dignity and privacy was maintained for one resident who had an audiology consult in a public activities area for one of 36 residents (Resident R13).

Inspectors wroteBased on review clinical record, review of facility documents, facility investigations, facility policy and interview with staff and residents, it was determined that the facility did not ensure that residents were free from misappropriation of resident property related to narcotic diversion for one of 36 residents (Resident R14). This deficiency was identified as Past Non-compliance.

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to ensure that one resident with a diagnosis of congestive heart failure was properly assessed after a 27.4-pound weight gain in a two-month time period, for one out of 29 residents reviewed (Resident R3).

Inspectors wroteBased on observation, review of clinical record, and interview with staff, it was determined that the facility did not ensure that residents receiving a tube feeding was placed in proper position to avoid aspiration for one resident (Resident R2). Review facility policy on two feeding Revealed that under section purpose to provide guidelines to ensure safe and effective administration of medications administered via Interlube under section procedure number 5 ensure head of bed is elevated unless contraindicated. Review of resident R2S clinical record revealed that resident R2 was admitted to the facility on [DATE], with diagnosis of but not limited to Dysphagia and get stressed and Gastrostomy Status. Review of Resident R2's MDS minimum data set significant change assessment dated [DATE], section K0520. [...]

Inspectors wroteBased on observation, interviews with staff, and review of clinical records, facility documentation, and policy it was determined that the facility did not implement an effective infection control program related to use of Personal Protective Equipment (PPE) and wound care for two of thirty-six residents observed (Resident R2 and Resident R5).

Inspectors wroteBased on clinical record review, observations, and interview with staff and residents, it was determined that the facility did not ensure that residents were free from neglect one of 5 residents reviewed. This deficiency is cited as past non-compliance. (Resident R3)Clinical record review revealed that Resident R3 was admitted to the facility on [DATE], with diagnoses including, but not limited to rheumatoid arthritis (a chronic condition in which the immune system attacks the lining of joints, causing pain, inflammation, stiffness, and potential deformity), and Huntington's Disease (an inherited, fatal disorder that causes progressive breakdown of nerve cells in the brain). Review of facility incident report revealed that during continence care on January 9, 2026, Resident R3 was repositioned by nurse aide, Employee E3, who then slid with her pillow to the floor. [...]

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to maintain sanitary, and comfortable environment on one of two nursing floors observed. (1st Floor)

Inspectors wroteBased on review of facility policy, review of clinical records, obsesrvations, and staff interviews, it was determined that the facility failed to obtain, follow, and clarify physician orders related to medications and skin checks for two of 34 residents reviewed (Resident R84 and R64). Findings Include: Review of facility document titled Administering Medications revised January 22, 2024, revealed medications shall be administered per providers written or verbal orders upon verification of the right medication, dose, root, time and positive verification of resident's identity. Medications may only be administered to the individual in which the medication was prescribed. [...]

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure professional practice standards related to pain management for one of 35 residents reviewed (Resident R260).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for two of two resident reviewed. (Residents R138, and R38)

Inspectors wroteBased on review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain accurate documentation of arbitration agreements for five of six arbitration agreements reviewed (Residents R37, R122, R48, R136 and R410).

Inspectors wroteBased on review of facility policy, review of clinical records, and staff and family interviews, it was determined that the facility failed to ensure resident representatives had the opportunity to participate in the care planning process for one of 35 residents reviewed (Resident R31). Findings Include: Review of facility policy Care Conference revised June 20, 2023, revealed the purpose of the policy is to provide interdisciplinary communication with the resident and/or legal representative for purposes of the development of an individualized comprehensive plan of care. The resident and/or their representative will receive communication in advance of the scheduled care conference. [...]

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a clean and homelike environment in resident care areas and dining experience for one of four nursing units observed (Main Unit). Findings Include: Observations on April 28, 2025, at 11:08 a.m. revealed Resident R95's breakfast tray, with leftover food on the tray, was left on the windowsill in the dining room on the Main Unit. Continued observations in the dining room on the Main Unit revealed the railing on the wall was broken. Further observations on April 28, 2025, at 12:35 p.m. as resident's gathered in the dining room to have lunch on the Main Unit revealed Resident R95's breakfast tray was still left on the windowsill. Observations were confirmed by Registered Nurse, Employee E6. Observations on April 28, 2025, at 12:45 p.m. [...]

Inspectors wroteBased on review of facility policies, review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that residents were free from verbal abuse, for two of four residents reviewed for abuse (Residents R135 and R361).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure residents were free from physical restraint for one of 34 residents reviewed (Resident R310). Findings Include: Review of facility policy Physical Restraints revealed physical restraints are only used when they are used appropriately to treat the resident's medical symptoms and to promote an optimal level of function for the resident. A restraint may never be used for the purpose of discipline or staff convenience. Per the facility policy, a physical restraint includes all devices and practices that restrict freedom of movement or normal access to one's body. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers to the hospital and that a resident's representative was made aware of a facility-initiated transfer in writing, for two of two clinical records reviewed. Resident R37 and Resident R119. Findings Include: Interview with Facility Administrator Employee E1 conducted on May 1, 2025 at 2:24pm revealed that the facility does not have a policy on discharge notification. Review of Resident R119's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Cerebral Atherosclerosis, Poly-osteoarthritis. [...]

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a person-centered comprehensive care plan related to behaviors for one of 35 residents reviewed (Resident R135).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interview, it was determined that the facility failed to timely provide feeding assistance for a dependent resident for one of 34 residents reviewed (Resident R78). Findings Include: Review of facility policy Activities of Daily Living (ADLs) revealed the facility will provide care and services for eating, assistance with feeding or preparation of meals. Based on the assessments, a personalized care plan is created and outlines the level of assistance needed for activities of daily living. [...]

Inspectors wroteBased on review of facility documents, review of clinical records, observations, and staff interviews, it was determined that the facility failed to implement both group and individual activities to meet the needs of each resident for 15 of 39 residents on the Main Nursing Unit (Resident R31, R78, R51, R71, R21, R142, R88, R4, R111, R133, R125, R131, R117, R64, and R150). Findings Include: Review of the April 2025 Activities Calendar revealed on April 29, 2025, Coffee & Chat was scheduled for 10:00 a.m. and Fun & Fit Exercise was scheduled for 11:15 a.m. on the Main Nursing Unit. Observations on April 29, 2025, at 9:45 a.m. revealed Resident R21, R88, R125, R64, and R131 were sitting in the dining room with no music and no television. These residents were observed to be sitting quietly with no stimulation. Follow up observations on April 29, 2025, at 11:45 a.m. [...]

Inspectors wroteBased on observations, review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of one resident reviewed with limited range of motion (Resident R101).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to obtain orders for oxygen for one of three residents reviewed who was receiving oxygen therary (Resident R410).

Inspectors wroteBased on review of personnel files, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for two of five newly hired personnel files reviewed (Employees E16 and E17).

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area. Findings Include: A tour of the main kitchen was conducted on April 28, 2025, at 9:32 a.m. with the Food Service Director, Employee E13. The tour included observations of the outside area where food deliveries are accepted and where the dumpsters are stored. Observations in the receiving area outside revealed trash, food, and debris on the ground surrounding the dumpsters. On one dumpster, the door on the back was open, and trash was exposed. 28 PA Code: 201.14(a) Responsibility of licensee.

Inspectors wroteBased on review of personnel files, observations, and staff interview it was determined that the facility failed to ensure staff were qualified to provide feeding assistance for one of one employee reviewed (Employee E27). Findings Include: Review of Resident R124's comprehensive care plan revised December 30, 2024, revealed the resident exhibited dysphagia (swallowing difficulties) when consuming foods by mouth putting the resident at risk for aspiration (inhaling food or saliva into the airway or lungs) and weight loss. Continued review of Resident R124's comprehensive care plan revised June 30, 2023, revealed the resident had an activities of daily living self-care performance deficit and required supervision assistance with eating. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of five residents on enhance barrier precaution observed (Residents R410). Findings Include: Review of facility Policy on Enhanced Barrier Precaution with an issue date of March 26, 2024 revealed that under section Policy, It is the Policy of this facility that Enhanced barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high0contact resident activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as residents with Chronic wounds requiring a dressing, indwelling medical device or residents with infection or colonization with an MDRO. [...]

Inspectors wroteBased on observations of the physical environment, interviews with staff and residents, it was determined that the facility failed to maintain an effective pest control program.

Inspectors wroteBased on clinical record review, facility policy, resident and staff interview, it was determined that the facility failed to ensure complete and accurate treatment administration for one of 10 residents reviewed (Resident CL1).

Inspectors wroteBased on observations, review of facility policies, facility documentation and interviews with staff, it was determined the facility failed to ensure water temperatures in the central shower room and resident bathroom sinks were maintained at a safe temperature for one of four nursing units observed (TCU Nursing Unit). This failure placed residents on the TCU Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was 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 R1, R2 and R3).

Inspectors wroteBased on observations, review of facility policies and interviews with residents and staff, it was determined that the facility failed to provide a comfortable environment related to water temperatures for two of four nursing units observed (First and Second Floor Nursing Units).

Inspectors wroteBased on review of facility records, job description, and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to ensure that water temperatures in the central shower room and resident bathroom sinks were maintained at a safe temperature for one of four nursing units observed (TCU Nursing Unit). This failure placed residents on the TCU Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to obtaining medical records in a timely manner for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on clinical record reviews, interviews with staff, reviews of hospital records and facility policies and procedures, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after they were hospitalized . (Resident R1)

Inspectors wroteBased on observation, review of clinical record, review of facility policies, interview with staff and resident, it was determined the facility failed provide tracheostomy care consistent with professional standards of practice for one of one resident observed. This failure resulted in an Immediate Jeopardy situation for Resident R130 who was decannulated, experienced respiratory and emotional distress and potential death. (Resident R130)

Inspectors wroteBased on observation, staff interview and review of facility policy, it was determined that the facility failed to ensure that personal privacy was maintained related to patient care and tracheostomy care for one of 35 residents observed. (Resident R130)

Inspectors wroteBased on closed clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that resident assessments were completed in a timely manner for one of three discharged records reviewed (Residents R77).

Inspectors wroteBased on review of clinical records, interview with staff and review of facility policy, it was revealed that the facility failed to revise a resident's PASARR (Pre-admission Screening and Resident Review) with mental health diagnosis for one of 35 resident's records reviewed (Resident R77).

Inspectors wroteBased on observation, record review and interview with staff, it was determined that the facility failed to develop a resident's care plan related to oxygen therapy for one of 35 clinical records reviewed. (Resident R112).

Inspectors wroteBased on observation, record review and interviews with staff and resident, it was determined that the facility failed to ensure a physician order was obtained realated to oxygen therapy for one of 35 clinical records reviewed. (Resident R112).

Inspectors wroteBased on observations, review of clinical records and interview with staff, it was determined that facility did not ensure to provide sufficient services to restore bladder function for one of 35 residents reviewed. (Resident R61)

Inspectors wroteBased on clinical record review, review of professional literature, review of facility policies and interviews with staff, it was determined that the facility failed to assess a PICC line in accordance with professional practice standards for two of four residents with peripheral central cathether lines (Resident R179).

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interview with staff and review of facility policy, it was determined that the facility failed to ensure proper infection control procedures during tracheostomy care for one of one resident observed with a tracheostomy. The facility failed to ensure the proper processing of lines and accessibility to hand washing station in the laundry. (Resident R130)

Inspectors wroteBased on observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe sanitary and functional environment for 6 residents and 15 residents rooms of two floors (Resident R1, R2, R3, R10, R14, R15; First, A, B, C and Second floor nursing units). Finding Include: Interview with Resident R1 on March 15, 2024, at 10:41 a.m. observations were made a dirty left over breakfast and of a take out order of scrambled eggs, steak and pasta . Resident R1 reported that it has been on her bedside dresser for two days and it's still here. Observations of Resident R1's restroom revealed a takeout container with dirty water being soaked on the top the toilet lid. [...]

Inspectors wroteBased on review of facility policy, and interviews with residents and staff, it was determined that the facility failed to establish grievance policies and procedures that include the right to file a grievance for 2 of 13 residents reviewed.

Inspectors wroteBased on observation, review of clinical record, review of facility documentation, review of facility policies and interviews with resident and staff, it was determined that the facility failed to ensure that residents were free from neglect during provision of care for one of nine residents reviewed. (Resident R1). This failure resulted in actual harm to Resident R1, who sustained a fall resulting in actual harm, transfer to the hospital and was diagnosed with a left femur fracture. (Resident R1) Findings Include: Review of the facility's policy titled Abuse revised October 24, 2022, revealed that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. [...]

Inspectors wroteBased on observations, clinical record review, and interviews with residents and staff, it was determined that the facility failed to provide adequate supervision to prevent accident hazards for one of nine residents reviewed (Resident R1) who sustained a fall resulting in actual harm, transfer to the hospital and diagnosed with a left femur fracture. (Resident R1) Findings Include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, including Muscle Wasting and Atrophy (the decrease in size and wasting of muscle tissue), Post-Traumatic Hydrocephalus (a serious complication that follows a traumatic brain injury), History of Falling, and Idiopathic Neuropathy (Nerve damage interferes with the functioning of the peripheral nervous system; when the cause cannot be determined, it is called idiopathic neuropathy). [...]

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide written notice, including reason for the change, prior to moving a resident to another room, for one of 38 residents reviewed (Resident R40).

Inspectors wroteBased on employee record reviews of newly hired employees, interviews with staff and reviews of facility policies and procedures, it was determined that for one of five employee records reviewed that the facility failed to initiate and complete a federal criminal back ground check.

Inspectors wroteBased on interviews and the review of clinical record, it was determined that the facility failed to ensure a complete and through investigation for an injury of unknown origin for 1 out of 39 residents reviewed (Resident R17).

Inspectors wroteBased on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered care plans related to caregiver preferences, and substance use disorder for two of 38 residents reviewed (Residents R9 and R183).

Inspectors wroteBased on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to obtain physician orders related to blood sugar monitoring (Resident R9) and failed to follow physician orders related to weights (Resident R22) for two of 38 residents reviewed.

Inspectors wroteBasedoninterviewswithresidentsandstaffandreviewofclinicalrecords itwasdeterminedthatthefacilityfailedtoensurethatoneresidentparticipatedintherestorativecarenursingprogramtomaintain improve orpreventavoidabledeclineinrangeofmotionandmobilityfor2 outof38 reviewed(ResidentR6 andR61).

Inspectors wroteBased on observation, interview with staff and residents, and review of clinical record, it was determined that the facility did not provide a safe environment related to possession of disposable razors for one of 38 residents (Resident R133).

Inspectors wroteBased on clinical record reviews, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for body weight and laboratory values for two of eight residents reviewed. (Residents R96 and R97)

Inspectors wroteBased on observation of medication administration, review of clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure the medication error rate was less than five percent.

Inspectors wroteBased on observation, review of facility policies, and interviews with staff, it was determined that the facility failed to ensure that medications were properly stored and labeled in two of five medication carts reviewed (Second floor B and C Wing medication carts).

Inspectors wroteBased on clinical record reviews, observations of the food and nutrition department, reviews of food committee meeting minutes and interviews with residents and staff, it was determined that the facility failed to provide residents with nourishing, palatable, well-balanced diets that met their daily nutritional and special dietary needs for 2 of four nursing units observed (first floor nursing and second floor nursing unit ).

Inspectors wroteBased on observation, interview with staff and review of facility policy and procedures revealed that the facility failed to maintain infection control practices related to hand hygiene for one of 38 residents (Resident R285).

Inspectors wroteBased on review of personnel files, review of facility polices and interviews with staff, it was determined that the facility failed to provide annual abuse training for two of four employees reviewed for abuse training (Employee E11 and E16).