EDENBROOK SOUTH

101 LEADER DRIVE, WILLIAMSPORT, PA 17701

Facility Assessment 21 federal violations at this facility remain unresolved. Inspectors recorded 1 citation at the actual-harm level or worse in the last three survey cycles.

At or above the 2024 benchmark — review inspection history before visiting.

Quality Breakdown

RN Staffing Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.	0.57 — At or above the repealed 0.55 hr benchmark
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles) Violations found during federal inspections, with how many remain open and how many involved actual harm.	Total 70 Outstanding 21 Actual harm or worse (G–L) 1
CMS Ratings Overall and Staffing quality ratings from CMS (1-5 stars).	Quality: ★★★☆☆ (3/5) Staffing: ★★★☆☆ (3/5)
NursingHomeGrade Score	18/100

Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

1 actual harm issue found among 70 total deficiencies. 49 corrected. — 21 still outstanding

Most recent inspection (February 11, 2026)

E Potential harm — pattern F0604 Status: Outstanding — No Plan

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0880 Status: Outstanding — No Plan

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0726 Status: Outstanding — No Plan

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0730 Status: Outstanding — No Plan

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0947 Status: Outstanding — No Plan

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

F Potential harm — widespread F0812 Status: Outstanding — No Plan

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has no plan of correction

C No harm — widespread F0814 Status: Outstanding — No Plan

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0755 Status: Outstanding — No Plan

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

C No harm — widespread F0756 Status: Outstanding — No Plan

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0759 Status: Outstanding — No Plan

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0761 Status: Outstanding — No Plan

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.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0677 Status: Outstanding — No Plan

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0684 Status: Outstanding — No Plan

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0693 Status: Outstanding — No Plan

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.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0695 Status: Outstanding — No Plan

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0641 Status: Outstanding — No Plan

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0656 Status: Outstanding — No Plan

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0554 Status: Outstanding — No Plan

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0583 Status: Outstanding — No Plan

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0584 Status: Outstanding — No Plan

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.

Resident Rights Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0628 Status: Outstanding — No Plan

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 15, 2025

D Potential harm — isolated F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Past Non-Compliance

Inspection cycle 2 (May 22, 2024)

D Potential harm — isolated F0607 Status: Corrected

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 2, 2024

G Actual harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected April 26, 2024

D Potential harm — isolated F0607 Status: Corrected

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0710 Status: Corrected

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected July 2, 2024

E Potential harm — pattern F0726 Status: Corrected

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0806 Status: Corrected

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 22, 2024

F Potential harm — widespread F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0756 Status: Corrected

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 2, 2024

E Potential harm — pattern F0757 Status: Corrected

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 2, 2024

E Potential harm — pattern F0756 Status: Corrected

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

E Potential harm — pattern F0758 Status: Corrected

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0761 Status: Corrected

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

E Potential harm — pattern F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2025

D Potential harm — isolated F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2025

E Potential harm — pattern F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 22, 2024

E Potential harm — pattern F0688 Status: Corrected

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 22, 2024

D Potential harm — isolated F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 2, 2024

E Potential harm — pattern F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

E Potential harm — pattern F0688 Status: Corrected

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

E Potential harm — pattern F0584 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 10, 2024

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

D Potential harm — isolated F0584 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2025

Inspection cycle 3 (February 16, 2024)

B No harm — pattern F0732 Status: Corrected

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected August 1, 2023

F Potential harm — widespread F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

E Potential harm — pattern F0761 Status: Corrected

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 1, 2023

E Potential harm — pattern F0756 Status: Corrected

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

D Potential harm — isolated F0761 Status: Corrected

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

D Potential harm — isolated F0758 Status: Corrected

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

E Potential harm — pattern F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2023

E Potential harm — pattern F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2023

E Potential harm — pattern F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2023

D Potential harm — isolated F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

E Potential harm — pattern F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

D Potential harm — isolated F0688 Status: Corrected

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

E Potential harm — pattern F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

E Potential harm — pattern F0561 Status: Corrected

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2023

E Potential harm — pattern F0584 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2023

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

D Potential harm — isolated F0580 Status: Corrected

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

D Potential harm — isolated F0584 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 2, 2024

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EDENBROOK SOUTH

Quality Breakdown

Inspection Deficiencies

Most recent inspection (February 11, 2026)

Inspection cycle 2 (May 22, 2024)

Inspection cycle 3 (February 16, 2024)

How We Stay Independent

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