Inspection visit
Fire Safety inspection
Citations
33 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0015GeneralS&S Cno actual harm
Address subsistence needs for staff and patients.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0007GeneralS&S Cno actual harm
Address patient/client population and determine types of services needed.
- 0004GeneralS&S Cno actual harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Cno actual harm
Conduct risk assessment and an All-Hazards approach.
- 0018GeneralS&S Cno actual harm
Establish procedures for tracking staff and patients during an emergency.
- 0022GeneralS&S Cno actual harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Cno actual harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Cno actual harm
Establish policies and procedures for volunteers.
- 0025GeneralS&S Cno actual harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Cno actual harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Cno actual harm
Develop a communication plan.
- 0030GeneralS&S Cno actual harm
List the names and contact information of those in the facility.
- 0032GeneralS&S Cno actual harm
Provide primary/alternate means for communication.
- 0035GeneralS&S Cno actual harm
Provide family notifications of emergency plan.
- 0100GeneralS&S Cno actual harm
Meet other general requirements.
- 0131GeneralS&S Epotential for harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
- 0211GeneralS&S Cno actual harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0281GeneralS&S Epotential for harm
Install proper backup exit lighting.
- 0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0342GeneralS&S Fpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0912GeneralS&S Fpotential for harm
Have power receptacles that are properly grounded.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920GeneralS&S Epotential for harm
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the July 3, 2024 survey of EDENBROOK OF YEADON?
This was a inspection survey of EDENBROOK OF YEADON on July 3, 2024. The surveyor cited 33 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EDENBROOK OF YEADON on July 3, 2024?
Yes, 33 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Address subsistence needs for staff and patients."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.