F 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds
bed-hold policy.
Based 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)
Findings include:
Review of the undated policy titled Bed Hold and readmission Policy revealed that for those residents that
are transferred with an expectation of returning to the facility, the facility must comply with the requirements
related to discharge.
Clinical record review for Resident R1 revealed that this resident was admitted from the hospital on July 12,
2024, with diagnoses to include adjustment disorder with mixed anxiety and depressed mood (a
stressor-induced disorder that creates personal distress through symptoms of both anxiety and
depression).
The nursing note dated July 14, 2024, written by the nursing supervisor, Employee E11, indicated, Myself,
nurse and CNA went into resident's room to give care. During incontinent care, resident hit CNA in her
stomach. Md made aware, new order to send resident out to ER for evaluation for change in mental status
and behavior.
Further review of Resident R1's record revealed a nurses progress note dated July 14, 2024, indicating that
the resident was transported from the facility to the hospital at 5:35 p.m. for change in mental status.
Interview with Social Service Director on August 19, 2024, at 1:00 p.m. revealed that she was away from
the facility on Sunday, July 14, 2024, and was not involved with the hospital's subsequent inquiries for the
resident's readmission.
Interview with the Director of Nursing on August 19, 2024, at 1:05 p.m. revealed that Resident R1 did not
have any behaviors prior to him hitting the CNA on July 14, 2024, and that their admissions liaison was
working with the social worker at the hospital and had told the hospital that the facility did not have the
ability to care for the resident.
Interview on August 19, 2024, at 1:15 p.m. with the Regional Director of Business Development (RDBD),
who job duties include being liaison between their facilities and the hospitals to facilitate admissions and
readmissions. The RDBD indicated that when Resident R1 was admitted on Friday, he was fine, and then
Sunday he had the behavior and was sent to the hospital. The RDBD indicated her
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
395374
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2024
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 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
continued involvement with her following statements. The DON called me to let me know that Resident R1
had been sent out, and I called the emergency room and spoke to the attending physician and told him that
we could not handle the resident's behavior. I then asked to speak to a social worker and was told no one
would be available until Monday. On Monday, I reached out to the social worker at the hospital, Employee E
12, and said that we could not accommodate the resident, and she was sympathetic about the situation.
And that was it. Then about a week later I spoke to the hospital social worker who asked about placement
for Resident R1 asking if he would be able to return to our sister facility where he had originally discharged
. I told her that since his recent behavior they would not take him either, and said that typically they would
not pass a resident with such behaviors along to a sister facility.
Review of the MDS (Minimum Data Set, a comprehensive resident assessment) dated July 14, 2024,
Section A 310 F was coded 11 to indicate discharge assessment return anticipated.
The facility did not allow Resident R1, who transferred with the expectation of returning to the facility, to
return to the facility in a timely manner.
28 PA. Code 201.14(a)(b) Responsibility of licensee
28 PA. Code 201.29(c.3)(4) Resident rights
28 PA. Code 211.12(d)(1) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395374
If continuation sheet
Page 2 of 2
