01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-02-11 | 22 | 2026-02-11 | 6 |
| Cycle 2 | 2025-01-24 | 21 | 2025-01-24 | 7 |
| Cycle 3 | 2024-02-16 | 23 | 2024-02-16 | 6 |
CMS CCN 3953962026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Edenbrook South
101 Leader Drive · Williamsport, PA 17701 · Lycoming County
Certified beds116CMS provider file
Recent citation rows85current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
85 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 20 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-11 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0604Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0756Severity C · widespread; potential for minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0814Severity C · widespread; potential for minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · HEALTHF0947Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-02-11 · FIREK0211Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-11 · FIREK0225Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-11 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-04-0703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-05-02 | Fine | $10,824 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- No ownership disclosure row was matched in this release.
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.51per resident day
RN hours0.55per resident day
Weekend nurse hours3.27per resident day
Staff turnover61.2%CMS reported field