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Inspection visit

Inspection

EDENBROOK NORTHCMS #39536415 citations on this visit
15 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 15 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding access to space in a semi-private room for one of three nursing units (Second Floor Nursing Unit, Residents 19 and 42). Residents Affected - Few Findings include: Review of Resident 42's physician note dated April 12, 2023, revealed that they believe she is quite anxious, and this is contributing to her physical complaints at times .She does continue to order packages online quite frequently and this is becoming a hazard for her safety in her room. She is resistant to addressing this when staff has spoken to her. Difficult scenario. Review of Resident 42's care plan revised on May 19, 2023, revealed that she tends to order more personal items than her room can accommodate and insists on keeping an abundance in the bed or on her tray table. Observation on June 14, 2023, at 11:03 AM of Resident 42's (Bed A) and Resident 19's (Bed B) room confirmed that Resident 42 had an excessive amount of personal items, which included a small refrigerator, large screen TV, a large, two-door upright storage cabinet, fan, shelving units, bariatric bed, overbed table, and nightstand. Resident 42's bed was placed so that the closed privacy curtain was pushed over into Resident 19's side of the room. Resident 42's Oxygen concentrator was on the opposite side of the privacy curtain from her and within two feet of Resident 19's bed. Resident 42's items encompassed 75-80 percent of the semi-private room. Resident 19's bed was pushed over to the right side of her bed, which was pushing the window curtains into the windowsill/casing and inaccessible to the resident and staff. Resident 19 had a regular sized bed, a walker, overbed table, and nightstand. Concurrent interview with Resident 19 confirmed that Resident 42 does have several items encroaching on Resident 19's side on the room. Interview and observation of Residents 42 and 19's room on June 14, 2023, at 3:30 PM with the Nursing Home Administrator (NHA) acknowledged Resident 42's excessive items that are encroaching on Resident 19 with potential safety and access to resident concerns. She indicated that the facility had a meeting with Resident 42 regarding her on-line (Amazon) purchases and the space allotted for her use. Resident 42 agreed to order on-line items with deliveries on Wednesdays weekly, however, has not abided to this agreement. The NHA showed this surveyor the four to five medium sized packages delivered that day (Wednesday), but also indicated that Resident 42 had received several packages throughout the prior week since last Wednesday. The NHA was now Resident 42's package delivery person as (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 25 Event ID: 395364 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0558 Level of Harm - Minimal harm or potential for actual harm Resident 42 has informed several staff that she will report them if they don't give her what she's ordered, though safety concerns/space issues were identified. The facility failed to accommodate Resident 19's needs and preferences by ensuring that she had equal resident space in a semi-private room. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 2 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable environment on three of three nursing floors (first floor, second floor, third floor; Residents 28, 47, 4, 9, 98, and 117, 179). Findings include: Observation of the first floor nursing station on June 13, 2023, from 9:14 AM to 11:39 AM revealed the following: The wallpaper and the cove base molding located in the dining room was extremely dirty with spills covering the walls and cove base. A radiator directly behind a resident's dining table was bent and rusted, with sharp edges. Multiple dining chairs contained dried food debris on the frames of the chairs and dried spills were observed on the chair cushions. The wooden chair rail surrounding the dining area was significantly marred with exposed particle board material. The flooring in the dining area contained large, dried spills, dried food, dead bugs, and build-up of dirt and debris along the cove base molding where it meets the flooring. At the end of the resident hallway, the wall was significantly marred, with a hole in the wall. There was an electrical box with no cover and exposed wires. The above environmental concerns regarding the first floor dining room and hallway were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on June 14, 2023, at 2:25 PM. Observation of Resident 28's room on June 14, 2023, at 11:39 AM revealed that her dresser drawers were crooked and not able to be closed properly. There was another dresser in the room that was not being used but was missing the front piece of the bottom drawer. The door frame of the bathroom, on the left side was marred. Observation of Resident 47's room on June 13, 2023, at 2:03 PM revealed a build-up of dirt around the cove base to the right as you entered the room. The closet doors in the room were off track and leaning inward. The Nursing Home Administrator and Director of Nursing were made aware of the environmental concerns related to Resident 28 and 47 on June 14, 2023, at 2:16 PM. An observation of the second-floor nursing unit on June 13, 2023, at 11:19 AM revealed the wall area outside two shower room doors and extending down the hallway was significantly marred and contained holes/rips in the wallpaper. The flooring along the cove base was black with a buildup of dirt and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 3 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0584 Level of Harm - Minimal harm or potential for actual harm debris. The walls outside the shower room doors in the alcoves to the doors had visible dirt and debris marks on the walls. The environmental concerns on the second floor were reviewed with the Nursing Home Administrator and Director of Nursing on June 14, 2023, at 2:26 PM. Residents Affected - Some Observation of the Second Floor Nursing Unit revealed that there were several areas with drywall missing around and along the corner beads above the nurse's station and a 5 inch area of rough, unpainted, drywall patching above the doorway leading to Resident room [ROOM NUMBER] to 232 hallway. Observation of Resident 4's bathroom on June 14, 2023, at 9:05 AM revealed that the wall below the towel rack and to the left of the sink where the drywall was scuffed and marred measuring one foot in diameter. In Resident 4's room, there was a 9-inch tall by 3 inches wide area in the corner of the closet where the drywall was gouged, scuffed, ripped, and/or missing. Observation of Resident 9's room on June 14, 2023, at 9:11 AM revealed that the bathroom door jamb was marred, scuffed, and chipped from the floor up to one foot above the floor. Observation of Resident 98's room on June 14, 2023, at 9:33 AM revealed that there were three 3.5 inch long by 1-inch-wide drywall gouges above the head of her bed. Observation of Resident 117's room on June 13, 2023, at 9:18 AM revealed that there was a urine smell noted from her blankets and mattress. Observation of Resident 117's room on June 14, 2023, at 9:06 AM revealed the room's door and bathroom door jams were marred, scuffed, and chipped from the floor up to one foot above the floor. There was a strong urine smell noted in the room. Observation of Resident 179's room on June 14, 2023, at 9:14 AM revealed the baseboard to the left of the closet was peeling off the wall. The corner guard to the left of the closet was detached from the base and sliding down. The bathroom door jamb was marred, scuffed, and chipped. The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on June 14, 2023, at 2:15 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited deficiency 7/1/22 28 Pa. Code 201.18 (b) (1) (3) Management 28 Pa. Code 207.2 (a) Administrator's responsibility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 4 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman about resident transfers, for three of five residents reviewed for hospitalizations (Residents 26, 4, and 47). Findings include: Clinical record review for Resident 26 revealed the resident was transferred and admitted to the hospital on [DATE], returning to the facility on May 11, 2023. Resident 26 was also transferred and admitted to the hospital on [DATE] and returned to the facility on June 6, 2023. There was no evidence to indicate the facility notified the Office of the State Long-Term Care Ombudsman about the transfers to the hospital as required for the above resident. Clinical record review for Resident 47 revealed the resident was transferred and admitted to the hospital on [DATE], returning to the facility on January 12, 2023. Resident 47 was also transferred and admitted to the hospital on [DATE], and returned to the facility on April 21, 2023. Clinical record review for Resident 4 revealed that they were transferred to the hospital on May 12, 2023, and June 3, 2023, after there was a change in their condition. There was no evidence to indicate the facility notified the Office of the State Long-Term Care Ombudsman about the transfers to the hospital as required for the above residents. In an interview with the Nursing Home Administrator of June 16, 2023, at 1:10 PM it was confirmed that the facility had not notified the Ombudsman as required of resident transfers out of the facility. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 5 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to identify and assess a resident's decline in activities of daily living (ADL) for one of three residents reviewed for an ADL decline (Resident 57). Residents Affected - Few Findings include: A review of Resident 57's Minimum Date Set (MDS, an assessment completed at specific intervals to determine care needs) assessments dated February 2, and April 26, 2023, noted nursing staff assessed Resident 57 as requiring supervision with set up help only for toileting. A review of 57's next quarterly MDS assessment dated [DATE], revealed nursing staff assessed Resident 57 as declining and requiring extensive assistance of two staff members for toileting. There was no documented evidence in Resident 57's clinical record to indicate that the facility identified or assessed Resident 57's decline in her toilet use. The surveyor reviewed the above findings for Resident 57 during an interview with the Director of Nursing and Nursing Home Administrator on June 15, 2023, at 2:37 PM. The facility was unable to provide any further documentation that the facility assessed Resident 57's decline in toilet use. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 6 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for five of eight residents sampled for activities of daily living (Residents 70, 87, 101, 28, and 30). Residents Affected - Some Findings include: Observation of Resident 70 on June 14, 2023, at 9:38 AM revealed her hair appeared unclean. Resident 70 was unable to be interviewed due to her current cognitive status. A review of Resident 70's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated May 17, 2023, indicated nursing staff assessed Resident 70 as requiring physical help of one staff for bathing. Review of Resident 70's task documentation (ADL, activities of daily living charting) revealed she has only received four showers in the last three months. Further review revealed 70's bathing preference was identified as preferring a shower twice a week. Observation of Resident 87 on June 13, 2023, at 10:05 AM revealed his hair appeared unkempt. Resident 87 was unable to be interviewed due to his current cognitive status. A review of Resident 87's most recent MDS dated [DATE], revealed that bathing did not occur. Review of Resident 87's task documentation revealed he only received three showers in the last three months. Further review revealed 87's bathing preference was identified as preferring a shower twice a week. Observation of Resident 101 on June 13, 2023, at 11:55 AM revealed his hair appeared unclean. Resident 101 was unable to be interviewed due to his current cognitive status. A review of Resident 101's most recent MDS dated [DATE], indicated nursing staff assessed Resident 70 as requiring physical help of one staff for bathing. Review of Resident 101's task documentation revealed he only received five showers in the last three months. Further review revealed 101's bathing preference was identified as preferring a shower twice a week. An interview with the Nursing Home Administrator and Director of Nursing on June 15, 2023, at 2:35 PM confirmed these findings. They were unable to provide any further documentation that Residents 70, 87, and 101 received staff assistance for bathing as per their preferences. Observation of Resident 28 on June 13, 2023, at 11:30 AM revealed her in bed with her hair disheveled and it appeared unclean. Resident 28 appeared to be sleeping at this time. Observation of Resident 28 on June 14, 2023, at 10:30 AM revealed her in bed sleeping with her hair disheveled and it appeared to be unclean. A review of Resident 28's most recent MDS dated [DATE], revealed that nursing staff assessed her as requiring physical help of one with bathing activity. Clinical record review of Resident 28's task documentation (computerized documentation where staff document daily care) revealed that Resident 28 preferred showers and was scheduled for showers every Wednesday and Saturday on the first shift (7:00 AM to 3:00 PM). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 7 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 28's shower documentation for the month of April 2023, revealed that she only received a shower on April 5, 2023, and April 26, 2023. She was given a bed bath instead of a shower on April 8, 12, 15, 19, 22, and 29, 2023. Review of Resident 28's shower documentation for the month of May 2023, revealed that there was no documentation for her scheduled shower on May 3, 2023, she refused a shower on May 6 and 10, 2023, and she received a bed bath instead of a shower on May 13, 20, 24, and 27, 2023. Review of Resident 28's shower documentation for June 1-14, 2023, revealed that she was provided a shower on June 1 and 14, 2023, she received a bed bath instead of a shower on June 3 and 10, 2023. Observation of Resident 30 on June 13, 2023, at 1:31 PM revealed his fingernails on both hands to be long and they appeared dirty. Concurrent interview of Resident 30 revealed that the staff do not take care of his nails and he is unable to take care of them due to having a stroke that affected his left side. Interview with the Director of Nursing on June 15, 2023, at 2:14 PM revealed that the expectation is that nail care would be completed with showers or bed bath and as needed when dirty or long. The facility failed to provide activities of daily living as scheduled and per their preference for Resident 28 and 30. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 8 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding treatments and physician ordered interventions for three of 25 residents reviewed (Residents 30, 97, and 117). Residents Affected - Some Findings include: Clinical record review for Resident 117 revealed a physician's order dated June 8, 2023, that staff were to weight her every day for 14 days. Review of Resident 117's clinical documentation revealed that staff did not weight Resident 117 on June 9, 11, or 12, 2023. The surveyor reviewed the above information during an interview on June 15, 2023, at 2:30 PM with the Nursing Home Administrator and Director of Nursing. Clinical record review for Resident 30 revealed a physician's order dated December 22, 2022, for facility staff to contact cardiology and obtain an appointment related to Resident 30 having syncopal (fainting)/unresponsive episodes as he has a pacemaker that was last checked in September 2022. Further clinical record review revealed no evidence that Resident 30 was seen by the cardiologist or that a pacemaker check was completed. Interview with the Director of Nursing and Nursing Home Administrator on June 15, 2023, at 2:06 PM revealed that the cardiology appointment and pacemaker checks were never done. The facility failed to provide the highest practicable care related to Resident 30's cardiac care and pacemaker checks. In an interview with Resident 97 on June 14, 2023, the resident stated she gained weight since she was admitted to the facility and most recently felt she gained it due to lymphedema in her right leg. The resident stated she was supposed to get treatment for it in the last couple weeks but hasn't, and it is getting so bad she can't bend her leg very well to walk. Resident 97 stated she asked physical therapy the day prior to look at it because she was supposed to get her leg wrapped. Clinical record review for Resident 97 revealed a physician's progress note dated June 8, 2023, documented at midnight, which noted a visit with the resident for the chief complaint of leg swelling, and the resident reports history of lymphedema and swollen and occasionally painful legs. The note indicated will add bilateral Ace wraps toes to knees during the day and remove at night. The cardiovascular review portion of the note, stated, legs swollen, and the assessment and plan again indicated lower extremity edema, bilateral Ace wraps toes to knees on during day and off at night, continue to trend weight. The resident was not observed wearing Ace wraps during the visit and further clinical record review did not reveal any active order to apply Ace wraps to the resident's legs. There was no nursing notes or administration records to indicate Ace wraps were applied to Resident 97's legs since the physician note dated June 8, 2023, or further assessment of the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 9 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0684 legs. Level of Harm - Minimal harm or potential for actual harm In an interview with the Nursing Home Administrator and Director of Nursing on June 14, 2023, at 2:30 PM they were not aware of Resident 97's need for Ace wraps or concerns with lower extremity edema. Residents Affected - Some A physician's order for Resident 97 to receive Ace wraps to her bilateral lower extremities from toes to knees on during the day and off at night was obtained on June 14, 2023, after it was brought to the attention of the Nursing Home Administrator and Director of Nursing in the interview noted above, and six days after the physician noted the plan for treatment. The Nursing Home Administrator indicated the physician's note was identified but an order was not written at the time of the note. 483.25 Quality of Care Previously cited 11/22/22 and 7/14/22 28 Pa. Code 211.10(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 10 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, review of facility documentation, and resident and staff interview, it was determined that the facility failed to ensure that a resident was safe to smoke for one of one resident reviewed (Resident 42). Findings include: Interview with Resident 42 on June 14, 2023, at 11:03 AM revealed that she smokes independently and without any staff intervention and/or monitoring. Clinical record review for Resident 42 revealed the facility admitted her on December 16, 2022. There was no documentation that indicated the facility completed a smoking assessment to ensure that Resident 42 was safe to smoke independently. This information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on June 15, 2023, at 2:25 PM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 11 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for three of five residents reviewed (Residents 25, 43, and 117). Residents Affected - Few Findings include: Review of the facility policy entitled Medications-Small Volume Handheld Nebulizer, last reviewed without changes on May 4, 2023, revealed that after medication administration, staff is to wash the cup and mouthpiece with warm soap water and air dry. When completely dry, store in a plastic bag. According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 25 revealed a current physician's order for staff to administer Oxygen 2 LPM (liters per minute) via nasal cannula (NC, tubing to deliver Oxygen via the nose) as needed for shortness of breath and/or cyanosis (bluish colored skin). Observation of Resident 25's Oxygen concentrator on June 13, 2023, at 9:25 AM revealed that his Oxygen was set at 1.5 LPM. The Oxygen humidification cannister (to moisten his nares) and Oxygen tubing were not dated as to when they were implemented. The humidification cannister was not connected to his Oxygen tubing and the port was exposed to air. Further observation of Resident 25 on June 14, 2023, at 9:25 AM and June 15, 2023, at 12:19 PM revealed that there was a nebulizer machine sitting directly on the floor beside his bed. On June 15, 2023, at 12:19 PM Resident 25 was not wearing his Oxygen NC. They NC was lying on the floor, unbagged, with the nares tubing ports located under his overbed table wheel. Clinical record review for Resident 43 revealed current orders for staff to administer Oxygen 2 LPM via nasal cannula as needed for Dyspnea (difficulty breathing). Observation of Resident 43's Oxygen concentrator on June 13, 2023, at 9:09 AM, June 14, 2023, at 9:17 AM and June 15, 2023, at 12:17 PM revealed that her Oxygen NC was unbagged and draped over the Oxygen concentrator. There was a bag available to place the NC in when not in use. Observation of Resident 117 revealed that there was a CPAP (continuous positive airway pressure) mask unbagged and lying on a shelf beside her bed on the following dates and times: June 13, 2023, at 9:16 AM June 14, 2023, at 9:21 AM June 15, 2023, at 12:15 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 12 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0695 The surveyor reviewed the above information for Resident 77 during with the Director of Nursing and the Nursing Home Administrator on June 15, 2023, at 2:30 PM. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10 (c)(d) Resident care policies Residents Affected - Few 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 13 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for four of four residents reviewed (Residents 24, 25, 73 and 97). Residents Affected - Some Findings include: The facility policy entitled, Administering Pain Medication Policy, last reviewed without changes on May 4, 2023, revealed that the facility will assess a resident's level of pain prior to administering non-narcotic or narcotic analgesics. Staff will follow the medication administration per the physician's order and utilize pain assessment tools including the 10 point pain intensity scale. The facility identified the numeric pain rating scale (parameters) indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 24 revealed current physician orders for Tylenol (a medication used to treat mild pain) 650 milligrams (mg) by mouth every four hours as needed for a pain rating of 1-7 and Percocet (a medication used to treat moderate to severe pain), 10-325 mg give one tablet by mouth every six hours as needed for pain of 6-10. Review of Resident 24's medication administration record (MAR) for April 2023, revealed that the facility administered Percocet to her on the following dates for pain ratings not indicated by the physician's order: April 1, 2023, for a pain rating of 5 April 3, 2023, for a pain rating of 5 April 9, 2023, for a pain rating of 0 April 16, 2023, for a pain rating of 5 April 19, 2023, for a pain rating of 5 Review of Resident 24's MAR for May 2023, revealed that the facility administered Percocet to her on the following dates for pain ratings not indicated by the physician's order: May 1, 2023, for a pain rating of 5 May 9, 2023, for a pain rating of 5 May 24, 2023, for a pain rating of 5 May 27, 2023, for a pain rating of 5 Review of Resident 24's MAR for June 1-13, 2023, revealed that the facility administered Percocet to her on the following dates for pain scales not indicated by the physician's order: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 14 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0697 June 1, 2023, for a pain rating of 3 Level of Harm - Minimal harm or potential for actual harm June 3, 2023, for a pain rating of 5 June 5, 2023, for a pain rating of 5 Residents Affected - Some June 6, 2023, for a pain rating of 5 June 8, 2023, for a pain rating of 5 Further clinical record review revealed that the facility administered Resident 24's as needed Percocet for her pain level ratings of 6 and 7, 20 times in April 2023, 30 times in May 2023, and 16 times from June 1-13, 2023. There was no indication in the clinical record to indicate how the facility determined to administer the as needed Percocet to Resident 24 instead of the as needed Tylenol for her pain level ratings of 6 and 7, when both medications were ordered for those pain levels. Resident 24 was administered as needed Percocet for pain 50 times in April 2023, 51 times in May 2023, and 25 times from June 1-13, 2023. There was no evidence in the clinical record that Resident 24's physician was notified of her uncontrolled pain the required excessive use of her as needed Percocet. The Nursing Home a\Administrator and Director of Nursing were made aware of the concerns with Resident 24's pain medication administration during a meeting on June 15, 2023, at 2:11 PM. The facility failed to provide the highest practicable care regarding Resident 24's pain management. Clinical record review for Resident 97 revealed a current physician's order for Oxycodone HCL (an opioid pain medication used to treat moderate to severe pain) to be administered every six hours as needed for pain. Resident 97 also had an active physician's order for Tramadol (an opioid pain medication used to treat moderate to severe pain) every eight hours as needed for pain. Resident 97 also had an order for Tylenol, as needed, for a pain level of one to three. Resident 97's as needed orders for Oxycodone HCL and Tramadol did not specify any pain level parameters as to what level of pain the medications should be administered. Resident 97 was ordered two opioid medications with the potential to be administered every 6 hours and the other every eight hours simultaneously. Review of resident 97's MAR revealed the resident had utilized the Oxycodone HCL several times from June 1 to 14, 2023, for a pain level of five to seven. An observation and interview of Resident 73 on June 13, 2023, at 11:45 AM revealed the resident sitting in a chair beside her bed. The resident stated she was having a lot of pain in her back and legs, and she received oxy. Clinical record review for Resident 73 revealed the resident had the following active orders for pain medication administration: Oxycodone HCL to be administered every six hours as needed for severe leg pain of a level six to 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 15 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0697 Acetaminophen (Tylenol) 1000 mg) to be administered every six hours as needed for a pain level of seven to 10. Level of Harm - Minimal harm or potential for actual harm Acetaminophen 650 mg every six hours as needed for a pain level of four to six. Residents Affected - Some Acetaminophen 500 mg every six hour as needed for a pain level of one to three. A review of Resident 73's medication administration record for June 2023, revealed the resident had not utilized any as needed Acetaminophen during the month. Resident 73 was administered the Oxycodone HCL on June 13, 2023, at 10:59 AM for a pain level of seven, and again at 7:41 PM for a pain level of 4. Resident 73 was administered the Oxycodone HCL, for a pain level of 4, although the parameter for administration was seven to 10, and the as needed acetaminophen dose of 650 mg was not administered. There was also no evidence to indicate which area Resident 73 was having pain as the Oxycodone HCL is ordered for severe leg pain and overlaps with Acetaminophen 1000 mg to also be administered for a pain level of seven to 10. In a follow up interview with Resident 73 on June 14, 2023, at 8:45 AM the resident was again sitting in the chair by her bed. The resident stated she was starting to feel better as she had been nauseated since she took oxy yesterday. The above information regarding Resident 97 and 73's pain medications were reviewed in an interview with the Nursing Home Administrator and Director of Nursing on June 14, 2023, at 2:30 PM. Clinical record review for Resident 25 revealed physician's orders for the following pain medications: Ordered on March 8, 2023, Tylenol (for mild pain) 325 (mg 2 tablets by mouth (PO) every 6 hours as needed (PRN) for mild pain. Ordered on May 23, 2023, and discontinued on June 6, 2023, Oxycodone (for moderate to severe pain) 5 mg PO every 6 hours PRN for pain. Ordered on June 6, 2023, and discontinued on June 13, 2023, Oxycodone 5 mg PO every 6 hours PRN for breakthrough pain. Ordered on June 13, 2023, and discontinued on June 14, 2023, Oxycodone 5 mg PO every 2 hours PRN for pain or dyspnea related to abdominal pain. Ordered on June 14, 2023, Oxycodone 5 mg PO every 2 hours PRN for moderated to severe pain and/or dyspnea related to abdominal pain. There was no documentation that the facility identified which pain medication that staff were to administer for mild, moderate, and/or severe pain parameters or that the facility identified that multiple medications were available for the same pain parameter. Review of Resident 25's March, April, May, and June 2023 MAR (medication administration record, a form to document medication administration) revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 16 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0697 Staff administered the following PRN pain medications: Level of Harm - Minimal harm or potential for actual harm Tylenol 325 mg 2tablets PO every 6 hours PRN for mild pain March 9, 2023, at 9:40 PM for a pain level of 5. Residents Affected - Some March 10, 2023, at 5:38 AM for a pain level of 6. March 12, 2023, at 10:52 AM for a pain level of 4. March 15, 2023, at 3:42 PM for a pain level of 4. March 17, 2023, at 8:10 PM for a pain level of 4. March 22, 2023, at 4:24 PM for a pain level of 4. March 24, 2023, at 6:00 PM for a pain level of 5. March 25, 2023, at 8:50 PM for a pain level of 4. March 29, 2023, at 7:41 PM for a pain level of 5. March 31, 2023, at 3:14 AM for a pain level of 4. April 6, 2023, at 3:57 PM for a pain level of 4. April 8, 2023, at 12:08 AM for a pain level of 10. April 8, 2023, at 7:36 AM for a pain level of 4. April 9, 2023, at 7:26 PM for a pain level of 0. April 10, 2023, at 4:15 PM for a pain level of 5. April 13, 2023, at 5:12 PM for a pain level of 0. April 14, 2023, at 4:52 PM for a pain level of 6. April 26, 2023, at 4:15 PM for a pain level of 4. April 27, 2023, at 9:02 AM for a pain level of 4. May 11, 2023, at 5:15 PM for a pain level of 5. May 11, 2023, at 10:34 PM for a pain level of 5. May 12, 2023, at 5:09 AM for a pain level of 5. May 14, 2023, at 11:59 PM for a pain level of 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 17 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0697 May 13, 2023, at 8:27 AM for a pain level of 0. Level of Harm - Minimal harm or potential for actual harm May 19, 2023, at 11:22 PM for a pain level of 6. May 20, 2023, at 1:35 PM for a pain level of 5. Residents Affected - Some May 20, 2023, at 6:15 PM for a pain level of 8. May 21, 2023, at 12:13 PM for a pain level of 6. May 27, 2023, at 10:59 PM for a pain level of 5. May 28, 2023, at 11:41 PM for a pain level of 5. May 29, 2023, at 11:43 PM for a pain level of 4. May 30, 2023, at 11:52 PM for a pain level of 5. May 31, 2023, at 11:50 PM for a pain level of 5. June 1, 2023, at 8:20 AM for a pain level of 8. June 1, 2023, at 11:58 PM for a pain level of 5. June 2, 2023, at 1:48 PM for a pain level of 5. June 3, 2023, at 8:25 AM for a pain level of 5. June 6, 2023, at 6:47 AM for a pain level of 5. June 8, 2023, at 11:33 AM for a pain level of 5. June 9, 2023, at 4:29 Am for a pain level of 5. Oxycodone 5 mg every 6 hours PRN for pain May 24, 2023, at 11:44 AM for a pain level of 0. May 24, 2023, at 7:35 PM for a pain level of 0. May 27, 2023, at 10:59 PM for a pain level of 5. May 28, 2023, at 11:37 PM for a pain level of 5. May 29, 2023, at 8:02 AM for a pain level of 0. May 29, 2023, at 11:43 PM for a pain level of 4. May 30, 2023, at 11:46 PM for a pain level of 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 18 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0697 May 31, 2023, at 11:49 PM for a pain level of 5. Level of Harm - Minimal harm or potential for actual harm June 1, 2023, at 8:19 AM for a pain level of 8. June 3, 2023, at 4:17 PM for a pain level of 3. Residents Affected - Some Oxycodone 5 mg every 6 hours PRN for breakthrough pain June 9, 2023, at 12:16 PM for a pain level of 0. Review of Resident 25's May and June 2023 MAR revealed the following: Staff administered Tylenol 325 mg 2 tablets and Oxycodone 5 mg simultaneously on May 27, 2023, at 10:59 PM for a pain level of 5. On May 28, 2023, at 11:37 PM staff administered Oxycodone 5 mg for a pain level of 5. At 11:43 PM (6 minutes later) staff administered Tylenol 325 mg 2 tablets for a pain level of 4. On May 29, 2023, at 11:43 PM staff administered Tylenol 325 mg 2 tablets and Oxycodone 5 mg simultaneously on for a pain level of 4. On May 30, 2023, at 11:46 PM staff administered Oxycodone 5 mg for a pain level of 5. At 11:52 PM (6 minutes later),staff administered Tylenol 325 mg 2 tablets for a pain level of 5. On May 31, 2023, at 11:49 PM staff administered Oxycodone 5 mg for a pain level of 5. At 11: 50 PM (1 minute later) staff administered Tylenol 325 mg 2 tablets for a pain level of 5. On June 1, 2023, at 8:19 AM staff administered Oxycodone 5 mg for a pain level of 8. At 8:20 AM (1 minute later), staff administered Tylenol 325 mg 2 tablets for a pain level of 8. Staff did not administer Resident 25's pain medications according to the physician ordered pain scale level(s) nor did they identify the potential for poly pharmacy and administered Tylenol and Oxycodone several times simultaneously or almost simultaneously in May and June 2023. The surveyor reviewed Resident 25's pain information during an interview with the Nursing Home Administrator and Director of Nursing on June 15, 2023, at 9:15 AM. 483.25 (k) Pain Management Previously cited July 1, 2022 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 19 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 73). Residents Affected - Few Findings include: Clinical record review for Resident 73 revealed a diagnosis of Chronic Post Traumatic Stress disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since admission in November of 2021. During an interview with Resident 73, on June 13, 2023, at 11:45 AM a door was heard slamming in the hallway outside the resident's room. Resident 73, yelled, Slam it again! and stated, That annoys me. Resident 73 then went on to state she doesn't go to the dining room because large crowds bother her anxiety, and loud noises bother her too, like the slamming of the housekeeping cart door, and raised voices. Resident 73 indicated she was abused as a child and married an abuser, and she doesn't sleep well, that it is just hard for her body to shut down. A review of Resident 73's current plan of care revealed the facility identified the resident has the potential for ineffective coping related to stress from a traumatic event due to a history of abuse and a diagnosis of PTSD, and listed interventions of allowing the resident to express her feelings adequately and utilize positive coping mechanisms, consult with physician and psychiatry as needed, educate the resident to not get involved with incidents between residents and staff, and provide adequate time for the resident to discuss and explore her feelings. There was no evidence facility staff identified what Resident 73's specific triggers were that may retraumatize the resident or implemented measures into the resident's plan of care as to how facility staff can prevent/minimize triggers from occurring for the resident. The above information was reviewed with the Nursing Home Administrator and Director of Nursing during an interview on June 15, 2023, at 2:44 PM. 28 Pa Code 211.12 (a)(d)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.16(a) Social services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 20 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of five residents reviewed (Resident 58). Residents Affected - Few Findings include: Clinical record review for Resident 58 revealed that the facility admitted her on September 9, 2022, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). Review of a significate change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 2, 2023, indicated that the facility assessed Resident 58 as having the diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. Review of Resident 58's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview with the Director of Nursing and Nursing Home Administrator on June 15, 2023, at 3:08 PM confirmed the above findings for Resident 58. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 21 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based 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 one of five residents reviewed (Resident 42). Findings include: The facility policy entitled, Psychotropic medications, last reviewed without changes on May 5, 2023, revealed that as needed (PRN) psychotropic medications will not be administered without first trying non-medicinal interventions. The medication nurse, prior to administering a PRN psychotropic medication will attempt non-medicinal interventions and document the results of these interventions in the behavioral intervention record. Three alternative interventions must be attempted prior to administering PRN psychotropic medications. All residents who are ordered psychotropic medications will have a behavior intervention record. The medication nurse and the charge nurse will document daily on the behavior intervention record if a behavior has/has not occurred. Clinical record review for Resident 42 revealed that her physician saw her on March 16, 2023. They indicated that Resident 42 was very anxious and ordered Celexa and Ativan. Resident 42's physician ordered the following: On March 17, 2023, the physician ordered Celexa (for anxiety) 20 milligrams (mg) by mouth (PO) daily and Ativan (for anxiety) 0.5 mg PO every 8 hours as needed (PRN) anxiety. The max dose was 1.5 mg in 24 hours. There was no stop date identified for this PRN anxiety medication. On May 7, 2023, the physician increased Resident 42's Ativan to 1 mg PO every 6 hours PRN anxiety. The max dose was 3 mg in 24 hours. There was no stop date identified for this PRN anxiety medication. On May 4, 2023, Resident 42's physician saw her and indicated that she denied having Anxiety. Review of Resident 42's March, April, May, and June 2023 MAR (medication administration record, a form to document medication administration) revealed that staff was not monitoring Resident 42's behaviors to justify the initial Ativan order on or after March 17, 2023, or the Ativan increase on or after May 7, 2023. Review of a pharmacist recommendation dated April 17, 2023, revealed that the pharmacist identified that Resident 42's PRN Ativan should have a listed stop date. Please evaluate if the PRN Ativan can be discontinued or if a 14 day stop date can be added. The facility's physician did not address this until after the surveyor requested the pharmacist recommendation and physician response. The surveyor reviewed the above for Resident 42 during an interview with the Nursing Home Administrator on June 15, 2023, at 9:15 AM. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 22 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0758 28 Pa. Code 211.10(a) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 23 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential for food borne illness and maintain equipment in a clean and safe operating condition in the facility's main kitchen, and on three of three nursing units (first floor, second floor, and third floor). Findings include: An observation of the facility's main kitchen on June 13, 2023, at 8:30 AM revealed the following: A tiered cart beside the tray line area contained visible dust buildup and dried food debris. The lower shelf of the prep area contained dried food debris, and grease/dust build up. The flooring under and in between equipment was observed to have dirt and debris and buildup of both along the wall edges where they meet the floor. A three-tiered cart located beside the three-compartment sink contained a plastic tub of pens, stickers, and other supplies stored on it. It was significantly soiled with dust and dried debris on all shelves. A plastic container containing a white powdery substance was observed sitting on a preparation table in front of the blender. The container did not contain any identification of the white powdery substance or when it expired. A clear plastic measuring cup sat on top of the container uncovered, it contained a white powdery debris, and pieces of brown dried substance on the bottom of the measuring cup and on the lid of the container. The flooring in the dishwashing area contained dried black build up throughout, an area covered with metal diamond plate contained thick black buildup around the raised areas of metal and dried food debris. A floor drain in the area was covered in a dried black substance. The wall under the dish machine area was covered in dried brown and black splatter. A piece of conduit extending from the back of the dish machine to the eye wash station was covered in thick dust and large pieces of dried food. The flooring from the eye wash station, extending to the corner where a speed rack was stored around the door alcove back to the main kitchen area contained dried food, dirt, and debris. Visible dust was observed hanging from the light cover in the dish room area, as well as covering the ceiling beside it. A round vent next to the light was also covered in dust. Dust buildup was also observed along the dish room wall along the conduit extending from the ceiling to a control box on the wall. The two-door upright cooler was observed with dried spills, and dried red debris on the interior door seals and interior base. Dust buildup was observed in the dry storage area on the ceiling surrounding a sprinkler head and extending from the ceiling along the wall above the exit door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 24 of 25 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0812 Level of Harm - Minimal harm or potential for actual harm A review of the food temperature serving log at 8:45 AM on June 13, 2023, revealed temperatures were recorded for the breakfast that was served the morning of June 13, 2023, and lunch for June 13, 2023, which had not been prepared or prepped for serving, concurrent interview with Employee 1, dietary manager, confirmed lunch had not been served yet and the lunch serving temperatures should not have been recorded. Residents Affected - Many An additional storage area located outside the main kitchen concurrently observed on June 13, 2023, which Employee 1, indicated was a shared storage area, contained racks with clothing, facility equipment, food service paper products, and two chest freezers containing food. The flooring in the storage area was significantly soiled with dirt, black debris, footprints, and black smudges throughout the floor. Both chest freezers contained a thick buildup of ice on the interior. Employee 1 indicated she was not clear as to when the chest freezers were defrosted. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on June 14, 2023, at 2:23 PM. Review of the 2018 Air Gap International Plumbing Code revealed the following: 801.2 Protection. Devices, appurtenances, appliances, and apparatus intended to serve some special function, such as storage of ice or foods, that discharge to the drainage system, shall be provided with protection against backflow, flooding, fouling, contamination, and stoppage of the drain. 802.1.1 Food handling. Equipment and fixtures utilized for the storage, preparation and handling of food shall discharge through an indirect waste pipe by means of an air gap. 802.3.1 Air gap. The air gap between the indirect waste pipe and the flood level rim of the waste receptor shall be not less than twice the effective opening of the indirect waste pipe. Observation of the facility's ice machines on June 14, 2023, at 9:00 AM, for the Second Floor Nursing Unit; on June 15, 2023, at 12:23 PM for the Third Floor Nursing Unit; and on June 15, 2023, at 12:25 PM for the First Floor Nursing Unit revealed that they did not have a noted air gap between the ice machine drain at the floor drain. This surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing during an interview on June 15, 2023, at 2:30 PM. 28 Pa. Code 211.6 (c) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 25 of 25

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Citations

15 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0558GeneralS&S Dpotential for harm

    F558 - The right to reside and receive services in the facility with reasonable

    Reasonably accommodate the needs and preferences of each resident.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0623GeneralS&S Bno actual harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0676GeneralS&S Dpotential for harm

    F676 - Based on the comprehensive assessment of a resident and consistent with

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  • 0677GeneralS&S Epotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

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

  • 0684GeneralS&S Epotential for harm

    F684 - Quality of care

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

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

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

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

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

  • 0697GeneralS&S Epotential for harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0699GeneralS&S Dpotential for harm

    F699 - Trauma-informed care

    Provide care or services that was trauma informed and/or culturally competent.

  • 0744GeneralS&S Dpotential for harm

    F744 - A resident who displays or is diagnosed with dementia, receives the

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

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

  • 0223GeneralS&S Epotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0919GeneralS&S Epotential for harm

    F919 - Resident Call System

    Meet requirements for the use of electrical equipment.

FAQ · About this visit

Common questions about this visit

What happened during the June 16, 2023 survey of EDENBROOK NORTH?

This was a inspection survey of EDENBROOK NORTH on June 16, 2023. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EDENBROOK NORTH on June 16, 2023?

Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.