Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wedgewood Healthcare Center during CMS and state inspections, most recent first.
Missing Self-Administration Assessment and Order: A resident with intact cognition and diagnoses including COPD and HTN had meds at bedside, including inhalers and a Lasix tablet left from the prior day. Surveyors found no documented self-administration assessment or provider order authorizing the resident to self-administer meds, despite facility policy requiring both before self-administration.
Inaccurate MDS Coding for Discharge Planning: A resident with anxiety, emphysema, and COPD stated she wanted to return home and had been considering discharge since admission, while her care plan reflected a desire to return to a prior living setting. However, the MDS assessments coded discharge planning questions as No or Unknown despite staff noting ongoing uncertainty about her plans. The SS Director described the resident’s changing housing options and anxiety around calls from her former apartments, and the SS Assistant said he assumed she would be long term because she was no longer receiving therapy.
Failure to provide ADL care was identified for a cognitively intact resident who was dependent on staff for personal and toileting hygiene. The resident had a urinal left on the bedside dresser partially full of urine on repeated observations, dirty clothes left in a chair for several days, and a bed with food debris and stained sheets that had not been changed unless he asked. RN and CNA interviews confirmed staff were responsible for emptying urinals and taking clothes to laundry.
Improper urinary catheter management was identified for a resident with an indwelling catheter and diagnoses including obstructive uropathy, DM2, and BPH. Staff observed the catheter tubing on the floor, later compressed between the resident's legs with urine and sediment backing up, and a securement device was not secured to either leg during observations and catheter care. The record lacked catheter care orders, and the resident reported catheter care was not done daily and that he had chronic urinary infections.
A resident with anxiety, depression, heart failure, atrial fibrillation, alcohol use, and upper abdominal pain had a PRN lorazepam order. An RN administered the controlled medication after checking that it was too early, planned to document it later, and never entered the dose in the MAR. The Controlled Drug Administration Record and MAR were inconsistent, and the DON stated the nurse should have followed the five rights and documented the narcotic on both records.
Narcotics were not removed promptly and controlled drug documentation was incomplete for two residents. One resident’s lorazepam and morphine remained in the narcotic drawer after death, while another resident’s lorazepam count did not match the controlled drug record because an RN administered the PRN dose but did not sign it out on the controlled drug sheet.
A facility failed to ensure indwelling urethral catheter orders were in place for a resident with an indwelling catheter. The resident, with diagnoses including obstructive and reflux uropathy, was observed with a catheter, but the clinical record lacked documentation of catheter orders from late July to mid-November. The Director of Nursing indicated the orders were missed due to staff transition during the resident's readmission.
A facility failed to maintain accurate medication administration records for a resident prescribed Oxycodone for pain management. Discrepancies were found between the controlled drug administration record and the medication administration record over two months, with significantly fewer administrations documented in the latter. An LPN confirmed the procedure for documenting narcotic administration, which was not followed, as per the facility's policy.
The facility failed to address ongoing grievances from the Resident Council, including issues with room cleanliness, medication accuracy, and staff responsiveness. Residents reported repeated concerns about inadequate cleaning, insufficient snacks, and inconsistent meal services. Communication issues were also noted, with residents not being informed about the outcomes of their grievances or their rights. These deficiencies indicate a systemic failure to resolve resident concerns.
The facility's kitchen was found to be unsanitary during multiple inspections, with issues such as food debris, ice accumulation, and expired food items. Cleaning logs indicated tasks were completed, but observations contradicted this, and the Dietary Manager lacked policies for leftovers and cleaning.
The facility failed to secure smoking materials in a locked area when not in use, as observed in five residents. Smoking materials were found unsecured in residents' rooms and personal belongings, contrary to the facility's policy. The Social Services Director confirmed that residents were allowed to keep their smoking materials in their rooms, and lighters were not locked up, despite the policy requiring them to be secured.
A facility failed to monitor a resident's dialysis access site and notify the physician as required. The resident, with chronic kidney disease, had orders for monitoring the dialysis site for infection and assessing thrill and bruit every shift. However, documentation was missing for several shifts, and the resident reported swelling at the AV fistula site without immediate physician notification. Interviews confirmed the monitoring lapses and failure to follow the facility's policy for hemodialysis care.
A facility failed to follow infection control practices during incontinence care for a resident with severe cognitive impairment. An LPN and a CNA used the same area of wipes multiple times and did not apply barrier cream or dry the resident, contrary to the care plan and facility policy. The resident's wound dressing was also observed to be loose.
The facility failed to follow medication administration parameters and treatment orders for several residents, leading to deficiencies in care. A resident with hypertension was given medication without required blood pressure checks, and another resident's surgical incision treatment was not consistently documented. Additionally, a resident's blood pressure was not monitored as ordered, and another resident received medication despite readings outside prescribed parameters.
A facility failed to provide proper catheter care for a resident with a condom catheter, as documented in the treatment administration records for March and April 2024. The resident, diagnosed with a stage 4 sacral region pressure ulcer, required catheter care every shift and a weekly drainage bag change. However, records showed multiple instances of incomplete care and missed drainage bag changes. An LPN confirmed that completed treatments should be signed off, which was not done. The facility's policy required catheter care at least twice daily, highlighting a failure to adhere to this standard.
A CNA was observed exiting a resident's room with soiled items in gloved hands, violating the facility's infection prevention program. The program requires soiled items to be bagged separately and gloves removed before leaving the room.
Missing Self-Administration Assessment and Order
Penalty
Summary
The facility failed to ensure a self-administration assessment was completed for a resident who had medications at bedside and was taking medications independently. During an observation in the resident’s room, surveyors saw a medication cup with an oval white pill, an Albuterol hand-held inhaler, and an Anoro hand-held inhaler. The resident stated the pill in the cup was Lasix from the prior day that he had forgotten to take, and said the doctor had said it was okay for him to keep the rescue inhalers at bedside. Record review showed the resident had diagnoses including COPD, hypertension, and anxiety, and the admission MDS indicated cognition was intact. The November MAR showed the resident received Anoro Ellipta daily in the morning, Lasix 40 mg daily in the morning, and Albuterol Sulfate HFA as needed. The clinical record did not contain documentation of a self-administration medication assessment or a physician’s order authorizing self-administration. An RN stated that before a resident can self-administer medications, the resident should be assessed for self-administration and a physician’s order should be in place.
Inaccurate MDS Coding for Discharge Planning
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for one resident. The resident had diagnoses including generalized anxiety disorder, emphysema, and chronic obstructive pulmonary disease. During an interview, the resident stated she wanted to return home to her apartment and was waiting for a call that one had opened, and she said she had been planning to return home since admission but had experienced setbacks that caused uncertainty. Her care plan indicated she wished to be discharged to her prior assisted living facility and included establishing a pre-discharge plan and evaluating progress as needed. The Quarterly MDS assessment indicated the resident was alert and oriented, had no mood or behavior issues, and required setup or supervision for all ADLs, bed mobility, and transfers, but the discharge section answered No to return to the community and No to whether an active discharge plan was in place. The Annual MDS assessment also indicated the resident was alert and oriented, had no mood or behavior issues, and was independent for ADLs, bed mobility, and transfers, but answered No to active discharge planning already occurring and Unknown or uncertain to whether the resident wanted to talk to someone about leaving the facility and returning to live and receive services in the community. The Social Services Director stated the resident had become too small for one apartment option, later learned she could return to her former apartments, and remained uncertain about her plans, while the Social Service Assistant said he was catching up on notes and MDS assessments and assumed the resident would be long term because she was on the Rehabilitation Hall and no longer receiving therapy. The DON stated there was no policy addressing MDS coding and that the RAI manual was followed.
Failure to Provide ADL Care for Toileting and Laundry Needs
Penalty
Summary
Failure to provide ADL care related to toileting hygiene and laundry was identified for one resident who was cognitively intact and dependent on staff to maintain personal and toileting hygiene. The resident had diagnoses including spinal stenosis, weakness, major depressive disorder, and anxiety, and the care plan identified an ADL deficit related to weakness. During observation, the resident had a urinal sitting on the bedside dresser partially full of urine, and he stated it had been there from the night shift and had not been emptied. His bed also had food debris and brown spots on the sheets, and his chair contained a pile of clothing that he said staff were supposed to take to the laundry but had been there for several days. On later observations, the urinal was still sitting on the bedside dresser half full of urine, the dirty clothes remained in the chair, and the bed had not been changed. The resident stated he was going to gather his clothes and take them to the laundry himself, and he indicated staff only changed his bed when he asked them to. RN and CNA interviews confirmed that CNAs or nurses should empty urinals and take residents' clothes to the laundry, and the CNA job description included providing personal care functions, responding to resident needs in a dignified and respectful manner, and maintaining a clean and pleasant environment.
Improper Urinary Catheter Management
Penalty
Summary
Appropriate care for a resident with an indwelling urinary catheter was not provided because the facility lacked catheter care orders in the clinical record, and the catheter drainage system was observed improperly managed. The resident had diagnoses including obstructive and reflux uropathy, muscle weakness, type 2 diabetes mellitus, need for assistance with personal care, osteoarthritis, and benign prostatic hyperplasia. The care plan directed staff to provide catheter care every shift and as needed, change the catheter per provider order and as needed, use enhanced barrier precautions, ensure a securement device was in place, and monitor for pain and signs and symptoms of UTI. The record also showed prior urine testing with Candida glabrata and later Klebsiella pneumoniae with Gram Negative Growth greater than 100,000 cfu/ml, and the resident had a history of ESBL. During observations, the catheter tubing was seen lying on the floor, later compressed between the resident's legs with dark yellow urine and sediment backing up in the tubing, and a securement device was not secured to either leg. During catheter care, the securement device was again not secured to either leg. The clinical record lacked documentation of catheter care orders, and the DON later identified the missing physician's orders and entered a new order. The resident stated that catheter care was not done daily and reported chronic urinary infections with antibiotics needed twice in July. CNA staff stated catheter care was performed every two hours and that they would report changes such as abdominal or back pain, discharge from the penis, or blockage.
Controlled medication was administered without timely MAR documentation
Penalty
Summary
The facility failed to ensure a controlled medication was administered and documented within the appropriate timeframe for one resident. During observation of the 500 Hall medication cart, Resident 6’s Controlled Drug Administration Record showed 13 tablets of 0.5 mg lorazepam remaining, while the medication card showed 12 tablets remaining. The lorazepam had last been signed out at 4:00 a.m. by an LPN. The resident’s record showed diagnoses including atrial fibrillation, upper abdominal pain, heart failure, alcohol use, depression, and anxiety, and the care plan identified use of anti-anxiety medication for anxiety disorder. The physician’s order directed 0.5 mg Ativan (lorazepam) every 8 hours as needed for anxiety for 14 days, and the resident’s MDS assessment indicated the resident was cognitively intact. During interview, RN 6 stated that on the day in question she checked the last administration time for lorazepam and determined it was too early, but administered the medication anyway and intended to document it later when it was time for the medication. She did not document the administration in the MAR. The September 2025 MAR showed the resident received lorazepam at 4:00 a.m. by LPN 10, and the order indicated the next dose could be given 8 hours later at 12:00 p.m., but the MAR lacked documentation of the dose given by RN 6. The DON stated the nurse should follow the five rights, administer the narcotic at the appropriate time, and sign it out on both the Controlled Drug Administration Record and the MAR; if the resident needed the medication early, the nurse should contact the Nurse Practitioner.
Narcotics Not Removed Promptly and Controlled Drug Record Not Completed
Penalty
Summary
The facility failed to ensure narcotics were disposed of in a timely manner and failed to document narcotic administration on the Controlled Drug Administration Record sheet for 2 of 32 residents reviewed. During observation of the 500 Hall medication cart, Resident 52’s lorazepam tablet, lorazepam liquid, and morphine tablet were still in the narcotic drawer even though each medication had last been administered earlier and the resident had died. Resident 52’s record showed diagnoses including bronchus or lung cancer, COPD, altered mental status, and bone disorders; the resident was severely cognitively impaired, received hospice services, and had care plan interventions for medication administration, monitoring for side effects, pain evaluation, and reporting breakthrough pain. Resident 6’s lorazepam 0.5 mg tablet count did not match between the Controlled Drug Administration Record sheet and the medication card, with 13 tablets recorded on the sheet and 12 tablets on the card. The MAR showed the lorazepam was administered as needed for anxiety, but RN 6 stated she should have signed out the narcotic when she pulled it and had not done so because she was rushing. Resident 6’s diagnoses included atrial fibrillation, upper abdominal pain, heart failure, alcohol use, depression, and anxiety, and the care plan addressed use of anti-anxiety medication and monitoring for side effects.
Lack of Indwelling Catheter Orders for Resident
Penalty
Summary
The facility failed to ensure that indwelling urethral catheter orders were in place for a resident with an indwelling urethral catheter. Resident D, who had diagnoses including indwelling urethral catheter and obstructive and reflux uropathy, was observed with an indwelling catheter in place. The care plan for Resident D, dated 8/6/24, included interventions such as changing the catheter per medical provider orders and providing catheter care every shift. However, the clinical record lacked documentation of any indwelling catheter orders from 7/26/24 until 11/13/24. During an interview, the Director of Nursing indicated that the orders were missed due to the transition of staff when the resident was readmitted. The Regional Director of Clinical Operations provided a document titled Catheter Care, which stated the facility's policy to provide resident-centered care. Despite this policy, the absence of documented orders for the indwelling catheter care for Resident D from late July to mid-November represents a deficiency in the facility's adherence to its own care protocols.
Inaccurate Medication Administration Record for Pain Management
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medication administration record for pain management. Resident C, who had diagnoses including osteomyelitis and a stage 4 pressure ulcer to the sacrum, was prescribed Oxycodone 10 mg every 4 hours as needed for pain. However, discrepancies were found between the controlled drug administration record and the medication administration record for September and October 2024. In September, the controlled drug record indicated the medication was given 90 times, while the medication administration record showed it was documented only 13 times. Similarly, in October, the controlled drug record showed 38 administrations, but the medication administration record documented only 19. During an interview, an LPN confirmed that when a narcotic pain medication is administered, it should be signed out on the controlled drug administration record and also documented on the medication administration record. The facility's policy, as provided by the Regional Director of Clinical Operations, stated that medications should be charted when given, indicating a failure to adhere to this policy. This deficiency was related to a specific complaint, highlighting a lapse in maintaining accurate medical records for Resident C.
Unresolved Resident Grievances in LTC Facility
Penalty
Summary
The facility failed to promptly resolve grievances and recommendations made by the Resident Council during multiple meetings. Over the course of several months, residents consistently reported ongoing issues that were not addressed by the responsible departments. These issues included inadequate cleaning of rooms, insufficient snacks, lack of communication regarding medication changes, and problems with medication accuracy. Additionally, residents expressed concerns about the attitude and responsiveness of nursing staff, including aides not answering call lights in a timely manner and not knocking before entering rooms. Further grievances were raised regarding the maintenance and cleanliness of the facility, such as unclean bathrooms, broken furniture, and inconsistent laundry services. Residents also reported issues with meal services, including inconsistent serving times, incorrect meal tickets, and a lack of diabetic-friendly options. The facility's failure to address these concerns was evident as the same issues were repeatedly brought up in subsequent meetings without resolution. The Resident Council meetings also highlighted problems with communication and transparency. Residents were not informed about the outcomes of their suggestions or grievances, and there was a lack of awareness about their rights and the facility's rules. Additionally, residents were not provided with the necessary information to make complaints to the State Department of Health. These deficiencies indicate a systemic issue in addressing and resolving resident concerns, leading to ongoing dissatisfaction and unmet needs within the facility.
Sanitation Deficiencies in Kitchen Observed
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during multiple inspections. During the initial tour of the kitchen, several issues were noted, including crumbs and debris under food shelves in the dry storage room, a small blue cup improperly left in a sugar bin, and a heavily soiled seasoning storage bin. In the walk-in freezer, a significant amount of ice was found under the milk crates, and the walk-in refrigerator contained expired food items. The kitchen itself had various cleanliness issues, such as food crumbs and debris under tables, heavily soiled sinks, and a buildup of grease and food particles on kitchen equipment. A second observation confirmed that the issues identified earlier in the day remained unaddressed. Further inspections revealed persistent problems, including ice accumulation in the walk-in freezer, expired food in the refrigerator, and unclean kitchen surfaces. Additionally, inappropriate storage of cleaning supplies was noted, with bleach wipes found next to china cups in the dining room serving area. The facility's cleaning logs indicated that all tasks had been completed as assigned, yet the observed conditions contradicted these records. The Dietary Manager admitted to not having policies in place for handling leftovers and cleaning the kitchen, highlighting a lack of procedural guidance contributing to the unsanitary conditions.
Failure to Secure Smoking Materials
Penalty
Summary
The facility failed to ensure that smoking materials were secured in a locked area when not in use, as observed in five residents who were reviewed for accident hazards. Resident 6 was observed multiple times with cigarettes and a lighter on her bedside table, both while asleep and after meals. She admitted to hiding her lighter under her leg when leaving her room. Resident 54 kept her cigarettes and lighter in her purse, which she kept in bed with her. Resident 46 stored his smoking materials in his dresser or pocket without locking them up. Resident 86 kept her lighter on a picnic table while smoking outside, and Resident 72 stored her smoking materials in her purse, which she slept with due to the lack of a locking mechanism. The Social Services Director confirmed that residents were allowed to keep their smoking materials in their rooms and that lighters were not locked up, although residents were supposed to turn them in at bedtime. The facility's smoking policy required smoking materials to be secured in a locked area when not in use, but this was not being followed. The review identified 25 residents who smoked, including 8 with dementia, highlighting a significant oversight in securing potentially hazardous materials.
Failure to Monitor Dialysis Access Site and Notify Physician
Penalty
Summary
The facility failed to ensure proper monitoring and physician notification for a resident requiring dialysis care. The resident, who had a history of chronic kidney disease and other related conditions, was supposed to have their dialysis access site monitored for signs of infection and for the presence of thrill and bruit every shift, as per physician orders. However, the clinical records showed a lack of documentation indicating that these assessments were consistently performed. On multiple occasions throughout June, the Medication Administration Record (MAR) lacked documentation of the required monitoring of the resident's dialysis site and the assessment of bruit and thrill. This included several shifts where no records were made, indicating a failure to adhere to the physician's orders for monitoring. Additionally, there was an incident where the resident reported swelling at the AV fistula site, but the nurse did not notify the physician immediately, instead allowing the resident to decide when to inform the Nurse Practitioner. Interviews with facility staff, including an LPN and the Regional Director of Clinical Operations, confirmed that the monitoring was not conducted as required and that the physician was not notified of the edema at the fistula site. The facility's Hemodialysis Care and Monitoring policy outlined the need for immediate physician contact in such cases, but this protocol was not followed, leading to the deficiency.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident with multiple diagnoses, including severe cognitive impairment and frequent incontinence. During an observation, a Licensed Practical Nurse (LPN) used the same area of a wipe multiple times to clean the resident's genital area and performed improper hand hygiene by turning off the faucet with her bare hand. Additionally, the LPN did not dry the resident or apply barrier cream as required by the care plan. In a separate observation, a Certified Nurse Aide (CNA) also used the same area of a wipe multiple times during incontinence care and failed to apply barrier cream, citing it was out of stock. The resident was not dried, and the wound dressing was observed to be loose. The facility's policy on perineal care was not followed, as it required thorough washing, rinsing, and drying of the perineal and rectal areas.
Medication Administration and Treatment Deficiencies
Penalty
Summary
The facility failed to adhere to medication administration parameters for several residents, leading to deficiencies in care. Resident B, diagnosed with diabetes, hypertension, and morbid obesity, was prescribed Carvedilol and Hydralazine with specific blood pressure parameters. However, on multiple occasions in May and June 2024, these medications were administered without obtaining the required blood pressure or pulse readings. Additionally, Resident B's treatment for skin integrity issues was not consistently completed as ordered, with several missed applications of Nystatin cream. Resident D, who had hypertension and a surgical incision, also experienced similar issues with medication administration. The resident was prescribed Metoprolol Tartrate with specific parameters for blood pressure and pulse, yet the medication was administered multiple times in June and July 2024 without obtaining the necessary readings. Furthermore, the resident's surgical incision treatment was not documented as completed on several days in June 2024. Resident F, diagnosed with hypertension, had a care plan requiring daily blood pressure checks due to elevated levels. However, there was a lack of documentation for these checks from June 23 to June 26, 2024. Similarly, Resident H, with a diagnosis of hypertension, was administered Coreg despite blood pressure and pulse readings being outside the prescribed parameters or not obtained at all on several occasions in May, June, and July 2024. These failures in following physician orders and documenting care led to the identified deficiencies.
Failure in Catheter Care for Resident
Penalty
Summary
The facility failed to ensure proper indwelling catheter care for a resident with a condom catheter, as documented in the treatment administration records (TAR) for March and April 2024. The resident, who had a diagnosis including a stage 4 sacral region pressure ulcer, required catheter care every shift and a weekly change of the drainage bag. However, the TAR indicated multiple instances where catheter care was not completed on various dates and shifts, and the drainage bag was not changed as ordered on specific dates. During an interview, an LPN confirmed that any completed treatment should be signed off on the TAR, which was not done in this case. The facility's policy, as provided by the Regional Director of Clinical Operations, stated that catheter care should be performed at least twice daily for residents with catheters. This deficiency was related to a specific complaint, indicating a failure to adhere to the facility's catheter care policy.
Infection Control Breach by CNA
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by a staff member during one of five observations related to infection control. Specifically, a Certified Nursing Aide (CNA 4) was observed exiting a resident's room while wearing gloves and carrying a soiled brief in one gloved hand and a soiled pair of pants in the other. This action was contrary to the facility's infection prevention program, which requires soiled briefs and clothing to be placed in separate bags and soiled gloves to be removed before exiting a resident's room. The Regional Director of Clinical Operations provided a copy of the facility's Infection Prevention Program, which emphasizes the importance of reducing the risk of infections among residents and employees.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village Kentuckiana | 1.1 mi | ★★★★★ | 16 | 0 |
| Clark Rehabilitation And Skilled Nursing Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Rolling Hills Healthcare Center | 1.6 mi | ★★★★★ | 4 | 0 |
| Riverview Village | 2.4 mi | ★★★★★ | 1 | 0 |
| Charlestown Place At New Albany | 2.5 mi | ★★★★★ | 33 | 1 |
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