Pennsylvania Department of Health
EDENBROOK OF YEADON
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EDENBROOK OF YEADON
Inspection Results For:

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EDENBROOK OF YEADON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to a facility reported incident, completed on February 12, 2026, it was determined that Edenbrook of Yeadon was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

�483.12(a) The facility must-

�483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations: Based 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 March 11, 2024, 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." Continued review of the report revealed that the identified probable cause of the fall was that the plan of care was "not followed (requires 2 person assist with bed mobility)" [sic]. Review of the written statement of nurse aide, Employee E3 revealed that she had not utilized a second person for care because "I couldn't find helpwas with [their] clients. And I didn't want to wait cause she was wet." On February 12, 2026, the Nursing Home Administrator, employee E1, presented documentation indicating that the facility had initiated a plan of correction on January 9, 2026, related to neglect and following the plan of care for resident safety. Review of the facility's Plan of Correction documentation revealed the following: "1. Resident [R3] was assessed for injury on 1/9/26, with no injury noted. X-rays were ordered and results were negative on 1/12/26. 2. Current residents that require 2-person assistance for bed mobility were reviewed by nurse managers to ensure it is reflected accurately on the Kardex, completed on 1/13/26. 3. Nursing staff were educated on neglect/abuse and following the Kardex to provide the appropriate level of assistance starting on 1/14/26. Completion of education was achieved on 1/16/26. 4. Abuse questionnaire will be completed daily for 2 days. Audits will continue weekly x 4 weeks, and monthly x 3 months. IDT (Interdisciplinary Team) will bring results to QAPI (Quality Assurance Improvement Plan) for continued monitoring." Interview with Nursing Home Administrator, Employee E1 on February 12, 2026, at 12:15 p.m. revealed that Nurse aide, Employee E3 had been placed on administrative leave during the investigation and had been terminated when the facility substantiated abuse. The facility alleged a date of compliance with this plan of correction of January 16, 2026. Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of facility policies on abuse and neglect, as well as appropriate assistance levels during care. Random staff and resident interviews were conducted to verify compliance with the plan of correction. QAPI records reviewed to verify ongoing monitoring. Residents were observed receiving care with appropriate numbers of staff assisting. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(d)(5) Nursing Services

Plan of Correction - To be completed: 02/26/2026

Past noncompliance: no plan of correction required.

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