Edenbrook South
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on a review of facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of quality for three of six residents reviewed (Residents 1, 2, and 3).This deficiency is cited as past non-compliance.Findings Include: Review of facility reportable events and an abuse investigation report revealed that on October 2, 2025, Employe 2, NA (nurse aide), administered medications and completed medical treatments on behalf of Employee 1, LPN (licensed practical nurse), for Residents 1, 2, and 3. An interview with the DON (Director of Nursing) and the NHA (Nursing Home Administer) on December 23, 2025, at 11:30 AM revealed that on October 8, 2025, it was reported to the DON that Employee 2, NA, had administered medications. Review of Employee 2's statements revealed that on October 2, 2025, she had administered prescribed medications by oral (by mouth), PEG tube (Percutaneous Endoscopic Gastrostomy tube, is a tube surgically inserted through the skin of the abdomen directly into the stomach used to provide nutrition, fluids, and medications), and subcutaneous (a method of administering medication into the fatty tissue layer between the skin and muscle, typically performed using
a short needle) routes of medication delivery, as well as completing a dressing change (refers to the process of removing an old wound dressing and applying a new one) for 3 residents. Employee 2 stated
she completed a dressing change on Resident 1's surgical site, administered oral medications, and subcutaneous insulin to Resident 2, and administered medications via PEG tube and gave subcutaneous insulin to Resident 3. Employee 1, LPN, stated that she facilitated Employee 2, NA, in the administration of medications for Resident 2 and 3, and indicated that she was aware Employee 2 completed a dressing change for Resident 1. Interview with Resident 1 on December 23, 2025, at 10:47 AM revealed he recalled
a night when an NA had completed a treatment for him on his leg. Resident 2 and Resident 3 were not available for interview. Pennsylvania requires specialized training and credentialing for medications to be administered outside of the licensed practical nurse and registered nurse licenses. The facility failed to ensure care and services were provided in accordance with professional standards of quality. Review of facility documentation revealed that each resident was assessed on October 8, 2025, for any negative outcomes related to this event, and none were observed. The facility conducted Interviews with all nursing staff to determine if any similar events had occurred previously. Education on scope of practice and job duties for all nursing staff was initiated on October 8, 2025, and completed on October 14, 2025. Review of facility documents revealed routine auditing of medication administrations. Employees 1 and 2 were terminated. Review of facility documents revealed the demonstration and evidence of compliance audits and education. The above information was reviewed with the NHA and the DON on December 23, 2025, at 2:00 PM. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services
Residents Affected - Few
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
Event ID:
EDENBROOK SOUTH in WILLIAMSPORT, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WILLIAMSPORT, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EDENBROOK SOUTH or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.