Home / Pennsylvania / Williamsport
Edenbrook South
101 Leader Drive, Williamsport, PA 17701 · Lycoming County · (570) 323-3758
116 certified beds, about 87 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1977
Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395396 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on February 11, 2026, inspectors cited 21 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
Of 67 health citations since September 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $10,824 in the last three years; the largest was $10,824, and the latest is dated May 2, 2024.
Nurses and nurse aides worked 3.51 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.55 of those hours.
61.2% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
209/23
110/23
111/23
1302/24
105/24
505/24
108/24
309/24
1401/25
203/25
106/25
112/25
2102/26
107/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 67 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
36D
24E
3F
Potential for minimal harm
0A
1B
2C
July 6, 2026Complaint inspection · 1 citation
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to serve food at safe and appetizing temperatures on one of four hallways (East Hall).
February 11, 2026Standard inspection · 21 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen and store a resident's tube feed in a safe and sanitary location on one of four nursing units reviewed (North Hall Nursing Unit, Resident 11).
- E 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.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and safe environment on three of four nursing units (South, East and West, Residents 2, 8, 9, 29, and 85).
- E Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on clinical record review, review of select facility policies and procedures, and staff and responsible party interview, it was determined that the facility failed to obtain appropriate documentation for a device used as a physical restraint for one of one resident reviewed for restraint use (Resident 6).
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care for one of 19 residents reviewed for advance care planning (Resident 11), and one of three residents reviewed for skin conditions (Residents 3).
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 1, 2, and 3).
- E 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.
Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to secure medications on two of four nursing units (West and North, Resident 11).
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on clinical record review, review of select facility policies and procedures, and resident and staff interview, it was determined that the facility failed to determine a resident's capability to self-administer their medications for one of 19 residents reviewed (Resident 22).
- D Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure confidential personal and medical information in the facility's main lobby, one of four nursing units (North Hall Nursing Unit) and three of 19 residents reviewed (Residents 11, 53, and 60).
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of six residents reviewed for hospitalizations (Residents 3, 6, and 36).
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for 3 of 19 residents reviewed (Residents 29, 70, and 22).
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding a diagnosis for PTSD (Post-Traumatic Stress Disorder, a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) for one of 19 residents reviewed (Resident 9). Findings Include: During an interview with Resident 9 on February 8, 2026, at 1:38 PM, the resident stated he was diagnosed with PTSD related to a history of childhood sexual trauma. Clinical record review for Resident 9 revealed that the resident was diagnosed with PTSD on March 8, 2025. [...]
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, clinical record review, and resident family and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of four residents reviewed (Resident 11).
- D 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.
Inspectors wroteBased on clinical record review, observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services for a resident who is fed by enteral (feeding tube) means to prevent potential complications for one of one resident reviewed for tube feeding concerns (Resident 36).
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to store respiratory care equipment in a sanitary manner on one of four nursing units (South, Resident 33) and provide respiratory care consistent with professional standards of practice for one of two residents reviewed for respiratory concerns (Resident 4).
- D 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.
Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with wound vacs for four of four employees reviewed (Employees 4, 5, 6, and 7).
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to obtain and provide medications for one of 19 residents reviewed (Resident 20).
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent on one of four nursing units (North Nursing Unit; Residents 75 and 94).
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on a review of select facility policies and procedures, observation, and staff and resident interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of eight residents reviewed for infection control (Resident 22).
- D Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on a review of employee personnel and education records and staff interviews, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1).
- C Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on review of select facility policy and procedure and staff interview, it was determined that the facility failed to develop policies and procedures for the monthly medication regimen reviews that included time frames for the different steps in the process.
- C Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage.
December 23, 2025Complaint inspection · 1 citation
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on a review of facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of quality for three of six residents reviewed (Residents 1, 2, and 3). This deficiency is cited as past non-compliance. Findings Include: Review of facility reportable events and an abuse investigation report revealed that on October 2, 2025, Employe 2, NA (nurse aide), administered medications and completed medical treatments on behalf of Employee 1, LPN (licensed practical nurse), for Residents 1, 2, and 3. An interview with the DON (Director of Nursing) and the NHA (Nursing Home Administer) on December 23, 2025, at 11:30 AM revealed that on October 8, 2025, it was reported to the DON that Employee 2, NA, had administered medications. [...]
June 4, 2025Complaint inspection · 1 citation
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to obtain and provide medications for one of six residents reviewed (Resident 1).
March 4, 2025Complaint inspection · 2 citations
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record, review of select facility policies, and staff interview, it was determined that the facility failed to provide the highest practical care related to bowel management for one of four residents reviewed (Resident 1)
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of nine residents reviewed (Resident 1).
January 24, 2025Standard inspection · 14 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen.
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide activities of daily living (ADL) for two of five residents reviewed (Resident 65 and 89).
- E 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.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain or improve a resident's range of motion (ROM) and mobility for three of seven residents reviewed (Residents 42, 65, and 70).
- E 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.
Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes for four of four employees reviewed for competencies (Employees 4, 5, 6, and 7).
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to maintain pharmacy recommendations or evidence pharmacy recommendations were addressed by the physician for three of five residents reviewed (Residents 23, 42, and 49).
- E 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.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of five residents reviewed for medication regime review (Residents 9 and 65).
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to prevent the potential spread of infection during medication administration pass for two of five residents observed (Residents 10 and 60), during a dressing change for one of one resident observed for a dressing change (Resident 50), and failed to adhere to enhanced barrier precautions for one of one resident observed during observation of a dressing change (Resident 50).
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 21 residents sampled (Resident 61).
- D 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.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and safe environment on four of four nursing units (North, South, East and West, Residents 85, 56, 68, 14, 39, and 50 ).
- D Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record review, staff interview, and review of facility investigation documentation, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for one of two residents reviewed for abuse (Resident 42).
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 21 residents reviewed (Resident 52).
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure the highest practical care related to consultant recommendations for one of 21 residents reviewed (Resident 93).
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of three residents reviewed (Resident 43).
- D 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.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to secure treatments on one of four nursing hallways (North Hall, Resident 56).
September 12, 2024Complaint inspection · 3 citations
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide dependent residents with activities of daily living assistance for three of five residents reviewed (Residents 2, 3, and 4).
- E 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.
Inspectors wroteBased on clinical record review and staff and resident interview, it was determined that the facility failed to provide services for mobility deficits for two of five residents reviewed (Residents 2 and 4).
- D Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to provide food that accommodated resident preferences for one of five residents reviewed (Resident 5).
August 6, 2024Complaint inspection · 1 citation
- E 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.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on four of four nursing units reviewed (North, East, South, and [NAME] Nursing Units, Resident 1).
May 22, 2024Complaint inspection · 5 citations
- E Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on closed clinical record review and staff interview, it was determined that the facility failed to ensure each resident's medication regimen was free from unnecessary medications for one of five residents reviewed (Resident CR1).
- D Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of select facility policies and procedures, review of employee personnel records, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the required agencies an allegation of resident mental abuse for one of five residents reviewed (Resident CR1).
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide bathing assistance for a dependent resident for one of five residents reviewed (Resident CR1).
- D Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised the care of one of five residents reviewed (Resident CR1).
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on closed clinical record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist identified a potential medication irregularity for physician review for one of five residents reviewed (Resident CR1).
May 2, 2024Complaint inspection · 1 citation
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of select facility policies, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of five residents reviewed resulting in actual harm (Resident 1, East Hall Nursing Unit). This deficiency is cited as past noncompliance.
February 16, 2024Standard inspection, Complaint inspection · 13 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen and employee breakroom.
- E Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to provide treatment and services regarding skin assessments and treatments for four of five residents reviewed (Residents 27, 95, 93, and 82).
- E Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to provide care, consistent with physician orders, for the administration of supplemental oxygen for five of eight residents reviewed for oxygen use (Residents 27, 78, 97, 60, and 93).
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for two of six residents reviewed (Residents 58 and 24) and failed to ensure that the consulting pharmacist identified potential appropriateness for psychoactive medications for one of six residents reviewed (Resident 23).
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and resident and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for two of 21 residents sampled (Residents 27 and 56).
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to consult a physician for a deterioration in health status for one of seven residents reviewed for hospitalization (Resident 65).
- D 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.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide a clean and safe environment and maintain resident medical equipment free of disrepair on two of two nursing units (North and South Hall; Residents 60 and 65).
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observation, and resident, family, and staff interview, it was determined that the facility failed to assist with mouth care for residents requiring staff assistance for two of four residents sampled for activities of daily living (Residents 24 and 3) and nail care for one of four residents sampled for activities of daily living (Resident 3).
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician orders for one of three discharged residents reviewed (Resident 107) and care of a mediport for one of 21 current residents reviewed (Resident 56).
- D 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.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement interventions to address a decline in range of motion for one of one resident reviewed (Resident 95).
- D 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.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of six residents reviewed (Residents 23 and 107).
- D 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.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to secure medications on one of two nursing units (South Hall; Residents 36 and 82).
- B Post nurse staffing information every day.
Inspectors wroteBased on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to ensure accurate and complete daily nursing time posting for both units (North and South hall).
November 8, 2023Complaint inspection · 1 citation
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, it was determined that the facility to serve food in a sanitary manner on one of two nursing units (nursing station 2).
October 13, 2023Complaint inspection · 1 citation
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs for three of 11 residents reviewed (Residents 4, 5, and 6).
September 20, 2023Complaint inspection · 2 citations
- E Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, as well as staff and resident interviews, it was determined that the facility failed to ensure self-determination for resident's choices related to wake time schedules for 10 of 11 residents sampled (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11).
- E Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, review of select facility policies and procedures, and staff and family interview, it was determined that the facility failed to report, document, and investigate an injury of unknown origin for one of one resident sampled for injuries of unknown origin (Resident 13) and failed to implement interventions to prevent potential accidents for one of one resident reviewed (Resident 15).
Fire safety inspections
19 fire safety citations on file: 6 on February 11, 2026, 7 on January 24, 2025, 6 on February 16, 2024.
Every fire safety citation19 citations
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Inspect, test, and maintain automatic sprinkler systems.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- C Have simulated fire drills held at unexpected times.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Provide properly protected cooking facilities.
- E Have properly installed hallway dispensers for alcohol-based hand rub.
- E Inspect, test, and maintain automatic sprinkler systems.
- E Install corridor and hallway doors that block smoke.
- E Meet requirements for the use of electrical equipment.
- E Have proper medical gas storage and administration areas.
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- F Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Inspect, test, and maintain automatic sprinkler systems.
- E Install corridor and hallway doors that block smoke.
- C Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| May 2, 2024 | Fine | $10,824 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.51 | 3.89 | 3.86 |
| Registered nurses | 0.55 | 0.79 | 0.69 |
| All nursing staff on weekends | 3.27 | 3.53 | 3.42 |
| Nurse aides | 2.03 | ||
| Licensed practical nurses | 0.94 | ||
| Nursing staff turnover (share who left in a year) | 61.2% | 44.5% | 45.8% |
| Registered nurse turnover | 76.9% | 39.9% | 42.9% |
| Administrators who left | 6 |
CMS expects 3.71 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.61 on weekdays and 3.27 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 20.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.94 in April to June 2025 to 3.51 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.51 | 0.55 | 3.61 | 3.27 | 20.8% | 0 of 90 | 87 |
| Oct to Dec 2025 | 3.81 | 0.58 | 3.90 | 3.57 | 27.5% | 0 of 92 | 84 |
| Jul to Sep 2025 | 3.73 | 0.57 | 3.89 | 3.32 | 33.9% | 0 of 92 | 87 |
| Apr to Jun 2025 | 3.94 | 0.53 | 4.05 | 3.66 | 44.9% | 0 of 91 | 93 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Pennsylvania, Jan to Mar 2026 | 3.69 | 0.65 | 3.82 | 3.34 | 11.3% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 23.0 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.5 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.8 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.6 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 20.8 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.9 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 14.2 | 17.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.6 | 22.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 12.9 | 9.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.9 | 1.2 | 1.8 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 20 problems in this area, most recently on February 11, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 13 problems in this area, most recently on February 11, 2026: "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."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 11 problems in this area, most recently on February 11, 2026: "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."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 7 problems in this area, most recently on July 6, 2026: "Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.27 hours per resident per day, below the Pennsylvania average of 3.53.
- How long has the current administrator been here?CMS counts 6 administrators who left in the period it measured.
Other nursing homes nearby
- Edenbrook North Williamsport, 0 mi · 2 of 5 stars · 54 citations
- Wecare at Sycamore Rehabilitation and Nursing Cent Montoursville, 1.6 mi · 1 of 5 stars · 85 citations
- Williamsport Home, the Williamsport, 2.4 mi · 3 of 5 stars · 31 citations
- Valley View Rehab and Nursing Center Montoursville, 2.6 mi · 3 of 5 stars · 35 citations
- Rose View Rehab and Care Center Williamsport, 2.9 mi · 4 of 5 stars · 33 citations
- Muncy Place Muncy, 11.2 mi · 3 of 5 stars · 20 citations
- Watsontown Rehabilitation and Nursing Center Watsontown, 13.5 mi · 2 of 5 stars · 56 citations
- Jersey Shore Skilled Nursing and Rehabilitation Ce Jersey Shore, 15.6 mi · 1 of 5 stars · 61 citations
Pennsylvania contacts for a concern about a nursing home
These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Pennsylvania Department of Health, Division of Nursing Care Facilities, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Pennsylvania Long-Term Care Ombudsman Program, Department of Aging, 717-783-8975. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Pennsylvania Department of Health Nursing Care Facility Locator, where Pennsylvania publishes its own records on licensed homes.
Common questions
- What is Edenbrook South's Medicare star rating?
- CMS rates Edenbrook South 1 out of 5 stars overall, with 1 for health inspections, 2 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Edenbrook South get at its last inspection?
- 21 health deficiencies at the standard inspection on February 11, 2026. The Pennsylvania average is 10.
- Has Edenbrook South been fined?
- Yes. CMS lists 1 fine totaling $10,824 in the last three years.
- Does Edenbrook South accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Edenbrook South?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.