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.
Based 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).
Findings include:
Observations on the [NAME] Nursing Unit on August 6, 2024, between 9:05 AM and 9:15 AM revealed the
following:
The main dining room revealed three vents on the center of the ceiling that had an accumulation of what
appeared to be moisture related dark colored spots on the majority surface of the vents. A smaller vent on
the ceiling located near the perimeter of the ceiling with the wall had a significant accumulation of a
dust-like substance.
A nourishment ice cart at the South/West nurse station revealed a drip tray underneath the ice chest that
had a slimy, black colored substance accumulated on the entire perimeter of the drip tray.
There was a brown moisture stain on the ceiling tile near the exit sign.
A vent on the ceiling in the hallway in front of the South/West nurse's station was noted to have a significant
accumulation of moisture on it especially near the perimeter of the vent.
The nourishment room behind the South/West nurse's station had a smaller ceiling vent with a significant
accumulation of a dust-like substance.
Observation of the hallway on August 6, 2024, at 9: 27 AM located outside of the entrance to the main
kitchen revealed multiple ceiling tiles with brown colored water stains on them.
Observation of the South Nursing Unit on August 6, 2024, between 11:12 AM and 11:25 AM revealed the
following:
A lounge at the East/South intersection revealed four wall heating/air conditioning units with a black
substance accumulating on the vents. One unit had a significant accumulation of dead, small, winged
insects on the unit, in the vents, and on the floor surrounding the unit. There were three ceiling lights with
an accumulation of debris and dead insects in the protective coverings of the lights. A bug zapper on the
wall had a significant accumulation of dead insects on the unit, the ceiling above the unit, on the wall
surrounding the unit, and several cobwebs that contained dead insects that
(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 2
Event ID:
395396
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
395396
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edenbrook South
101 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
surrounded the unit.
Level of Harm - Minimal harm
or potential for actual harm
Nine ceiling lights in the resident hallway contained debris and dead insects accumulated in the protective
coverings to the lights.
Residents Affected - Some
Observation of the North Nursing Unit on August 6, 2024, at 11:30 AM revealed the following:
A large brown colored water-stained ceiling tile in the resident hallway that was warped.
A refrigerator at the East/North hallway revealed a significant accumulation of dust and debris on top of it
that included an unsmoked cigarette. There was a dried brown stain on the top of it. The top of the
refrigerator also contained an unopened container of Froot Loops cereal, a bottle of water, a box of gloves,
and several containers of hand sanitizer.
Observation of the ceiling vent in Resident 1's bathroom at 12:18 PM revealed a significant accumulation of
dust.
Observation of the physical therapy area at 12:39 PM revealed two vents with an accumulation of dust on
the vents and the surrounding ceiling tiles.
The above information was reviewed in a meeting with the Nursing Home Administrator and Director of
Nursing on August 6, 2024, at 2:40 PM.
28 Pa. Code 201.18(b)(3)(e)(2.1) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395396
If continuation sheet
Page 2 of 2
