
Report
TheVardellReport
Edenbrook South
Skilled nursing facility and nursing facility
101 Leader Drive
Williamsport, PA 17701

TheVardellReport
Skilled nursing facility and nursing facility
101 Leader Drive
Williamsport, PA 17701
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 13 inspections from October 2023 to July 2026, state surveyors documented 65 findings at Edenbrook South; 64 have a recorded correction and 1 awaits one; CMS lists 1 enforcement action in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 2 | 0 |
| 2024 | 5 | 23 | 1 |
| 2025 | 4 | 18 | 0 |
| 2026 | 2 | 22 | 0 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
21 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
14 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
5 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
13 findings
The same visit included a complaint investigation.
Enforcement Action
Civil money penalty, $10,824 imposed May 2, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 16, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F677 in February 2024, May 2024, September 2024, January 2025 and February 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F684 in October 2023, February 2024, January 2025, March 2025 and February 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F584 in February 2024, August 2024, January 2025 and February 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F756 in February 2024, May 2024, January 2025 and February 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F812 in November 2023, February 2024, January 2025 and February 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F688 in February 2024, September 2024 and January 2025. This citation covers care that keeps or improves a resident’s movement and mobility. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F695 in February 2024, January 2025 and February 2026. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F761 in February 2024, January 2025 and February 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F550 in February 2024 and January 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F607 in May 2024 and January 2025. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F641 in January 2025 and February 2026. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F726 in January 2025 and February 2026. The agency describes it this way: 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. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F755 in June 2025 and February 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F758 in February 2024 and January 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in January 2025 and February 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
F658 was cited in December 2025. This citation covers whether the home’s services meet professional standards of quality. The most serious was level D (no actual harm, potential for more). The December 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in five inspections, most seriously at level E.
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in five inspections, most seriously at level E.
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in four inspections, most seriously at level E.
What changed after F756 was cited, and how do you check it now?
Citation F756: cited in four inspections, most seriously at level E.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in four inspections, most seriously at level F.
What do you do to keep residents moving, and who provides range-of-motion care?
Mobility and Range of Motion: cited in three inspections, most seriously at level E.
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in three inspections, most seriously at level E.
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level E.
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in two inspections, most seriously at level D.
What changed after F607 was cited, and how do you check it now?
Citation F607: cited in two inspections, most seriously at level D.
Who completes resident assessments, and how are they checked for accuracy?
Accurate Assessments: cited in two inspections, most seriously at level D.
What changed after F726 was cited, and how do you check it now?
Citation F726: cited in two inspections, most seriously at level E.
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level D.
How many residents take psychotropic medications, and how often are doses reviewed for reduction?
Psychotropic Medications: cited in two inspections, most seriously at level E.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E.
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in one inspections, most seriously at level D. The December 23, 2025 citation has no recorded correction date.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
What led to the 2024 fine, and has it been paid?
A $10,824 civil money penalty was imposed May 2, 2024. CMS publishes the fine, not whether it has been paid.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Pennsylvania state survey agency.
Pennsylvania state survey agency
Inspection Oct 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Nov 8, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Feb 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection May 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection May 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Aug 6, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Sep 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Jan 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Mar 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Jun 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Dec 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Feb 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Pennsylvania state survey agency
Inspection Jul 6, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 395396
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowOctober 13, 2023 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.