Williamsport, PA

Edenbrook North

2-star overall rating with 2-star inspections with $305,250 in total fines with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

300 Leader Drive, Williamsport, PA

(570) 323-8627

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

152

Certified beds

Average residents

114

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Eden East Healthcare Management

Operator or chain grouping

Approved since

1977-04-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.43

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.87

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.84

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.13

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.30

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

2.81

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.22

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.50

CMS adjusted RN staffing hours

Adjusted total hours

3.61

CMS adjusted total nurse staffing hours

Case-mix index

1.19

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

69%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,315

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

6.71

Composite VBP score used to determine payment impact.

Payment multiplier

0.9806

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.90% · Performance 22.53% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0.59

Baseline 7.52% · Performance 7.66% · Measure score 0.59 · Achievement 0.59 · Improvement 0

Total nurse turnover

Baseline 46.39% · Performance 65.57% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.10

Baseline 3.43 hours · Performance 3.67 hours · Measure score 2.10 · Achievement 2.10 · Improvement 0.53

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.62%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 77 · Observed rate 12.99% · Lower 95% interval 7.58%
Discharge to community	46.44%	50.57% 4.1 pts worse	No Different than the National Rate · Eligible stays 60 · Observed rate 36.67% · Lower 95% interval 35.76%
Medicare spending per beneficiary	0.74	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 36 · Denominator 36
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 36
Discharge self-care score	67.86%	53.69% 14.2 pts better	Numerator 19 · Denominator 28
Discharge mobility score	75%	50.94% 24.1 pts better	Numerator 21 · Denominator 28
Pressure ulcers or injuries, new or worsened	5.56%	2.29% 3.3 pts worse	Numerator 2 · Denominator 36 · Adjusted rate 5.08%
Healthcare-associated infections requiring hospitalization	7.66%	7.12% 0.5 pts worse	No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 4.58%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 127
Staff flu vaccination coverage	49.21%	42% 7.2 pts better	Numerator 62 · Denominator 126
Discharge function score	78.57%	56.45% 22.1 pts better	Numerator 22 · Denominator 28
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	16.67%	25.2% 8.5 pts worse	Numerator 4 · Denominator 24

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.7 0.8 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.9	1.2 1.7 pts worse	1.8 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	73.3%	86.9% 13.6 pts worse	93.4% 20.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 64.5% · Q3 70.6% · Q4 77.8% · 4Q avg 73.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.4%	93.5% 4.9 pts better	95.5% 2.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4%
Percentage of long-stay residents experiencing one or more falls with major injury	7.9%	3.2% 4.7 pts worse	3.3% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 8.2% · Q3 9.2% · Q4 7.4% · 4Q avg 7.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.0%	6.5% 5.5 pts better	11.4% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	4.6%	6.5% 1.9 pts better	5.4% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.3% · Q3 5.1% · Q4 2.1% · 4Q avg 4.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	27.5%	19.9% 7.6 pts worse	19.6% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 29.3% · Q3 26.7% · Q4 24.5% · 4Q avg 27.5%
Percentage of long-stay residents who received an antipsychotic medication	26.7%	18.7% 8 pts worse	16.7% 10 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 27.6% · Q3 27.1% · Q4 22.2% · 4Q avg 26.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	12.1%	19.6% 7.5 pts better	16.3% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 19.0% · Q3 6.7% · Q4 11.9% · 4Q avg 12.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.2%	18.3% 3.1 pts better	14.9% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 17.5% · Q3 14.4% · Q4 12.9% · 4Q avg 15.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.9% 0.3 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.8% · Q4 0.7% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	1.7% 0.5 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.8%	26.4% 2.4 pts worse	19.8% 9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 37.4% · Q3 24.2% · Q4 27.0% · 4Q avg 28.8%
Percentage of long-stay residents with pressure ulcers	3.2%	5.3% 2.1 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.8% · Q3 5.1% · Q4 4.1% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	79.6%	68.9% 10.7 pts better	81.7% 2.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 78.7% · Q3 69.6% · Q4 79.7% · 4Q avg 79.6%
Percentage of short-stay residents who had an outpatient emergency department visit	22.4%	9.8% 12.6 pts worse	12.0% 10.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 24.1% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	1.5% 0.1 pts worse	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 3.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	81.9%	68.7% 13.2 pts better	79.7% 2.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.7%	23.1% 3.6 pts worse	23.9% 2.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 24.1% · Expected 21.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-04 · Fire 2025-04-04

15 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-05-23 · Fire 2024-05-23

21 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-06-16 · Fire 2023-06-16

19 health deficiencies

Top issue: Quality of Life and Care (11 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-04-04

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-05-28

E · Potential for more than minimal harm 2025-04-04

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-28

E · Potential for more than minimal harm 2025-04-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-28

E · Potential for more than minimal harm 2025-04-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-05-28

E · Potential for more than minimal harm 2025-04-04

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-05-28

C · Minimal harm 2025-04-04

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-05-28

C · Minimal harm 2025-04-04

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-05-28

E · Potential for more than minimal harm 2024-05-23

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-07-09

E · Potential for more than minimal harm 2023-06-16

K223 · Egress Deficiencies

Fire Safety

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

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-16

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2023-08-01

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-08

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-12-12

F · Potential for more than minimal harm 2025-04-04

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-05-13

E · Potential for more than minimal harm 2025-04-04

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2025-05-13

E · Potential for more than minimal harm 2025-04-04

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-13

E · Potential for more than minimal harm 2025-04-04

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-13

E · Potential for more than minimal harm 2025-04-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F744 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2025-05-13

D · Potential for more than minimal harm 2025-04-04

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-05-13

E · Potential for more than minimal harm 2024-09-19

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-22

E · Potential for more than minimal harm 2024-05-23

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

F699 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

F744 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-05-23

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-07-09