Deficiency Records for Yeadon Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Yeadon Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-21 | 2023-11-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-30 | 2023-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-30 | 2023-11-16 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-09-14 | 2023-10-30 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-09-14 | 2023-10-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-14 | 2023-10-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-30 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-14 | 2023-10-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-14 | 2023-10-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-14 | 2023-10-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-14 | 2023-10-30 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-14 | 2023-10-30 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-09-14 | 2023-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-30 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-14 | 2023-10-30 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-21 | 2023-10-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-21 | 2023-10-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-21 | 2023-10-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-21 | 2023-10-30 | N |
| Meet other general requirements. | Fire Safety | 2022-11-14 | 2023-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-14 | 2023-01-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Establish methods for sharing information. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-14 | 2023-01-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-09 | 2023-01-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-09 | 2023-01-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-11-09 | 2023-01-03 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-09 | 2023-01-03 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-09 | 2023-01-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-09 | 2023-01-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-09 | 2023-01-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-09 | 2023-01-03 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-09 | 2023-01-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-09 | 2023-01-03 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-09 | 2023-01-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-09 | 2023-01-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-09 | 2023-01-03 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-11-09 | 2023-01-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-11-09 | 2023-01-03 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-11-09 | 2023-01-03 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-11-09 | 2023-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-09 | 2023-01-03 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-09 | 2023-01-03 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-11-09 | 2023-01-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-09 | 2023-01-03 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-11-09 | 2023-01-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-09 | 2023-01-03 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-11-09 | 2023-01-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-09 | 2023-01-03 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-08-17 | 2022-09-09 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-17 | 2022-09-09 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-03-29 | 2022-04-29 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-27 | 2022-02-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-11 | 2022-02-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-21 | 2022-02-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-21 | 2022-02-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-21 | 2022-02-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-21 | 2022-02-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-21 | 2022-02-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-21 | 2022-02-04 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-12-21 | 2022-02-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-21 | 2022-02-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-16 | 2021-07-21 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-16 | 2021-07-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | Not Fixed | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-07 | Not Fixed | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-07 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-07 | Not Fixed | Y |
