Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Edgewood Manor Of Lucasville I during CMS and state inspections, most recent first.
Failure to Provide Proper Medicare Non-Coverage Notices: The facility failed to give three residents adequate notice that Medicare A therapy coverage was ending and did not document the right to appeal. The Medicare non-coverage notices lacked a legal signature showing verbal notice had been given, and the Administrator verified the residents were not provided the required 48-hour notice.
A resident with major depressive disorder, PTSD, and respiratory failure had a PASARR level one completed that did not identify mood disorder or other mental disorder for serious mental illness review. The MDS showed a BIMS of 15/15 and noted mood disorder and mental disorder, and the ADNS and DNS confirmed the omission during interview. The facility could not provide a PASARR policy.
A resident admitted with endocarditis and a PICC/IV access did not have a baseline care plan or PICC maintenance orders in place upon admission. The chart showed no documented PICC line maintenance care on the TAR for the first several days, and staff later confirmed the resident lacked PICC care orders until they were entered after admission; the DON also verified there was no baseline care plan for the PICC.
The facility failed to timely assess and treat a resident’s lower back pressure injuries, with no documented staging, wound description, measurements, or treatment orders until the wound CNP evaluated the areas and identified stage IV ulcers. The facility also failed to keep air mattresses at proper settings for two residents; one resident’s mattress was ordered and care planned but set far above the resident’s weight, and another resident’s mattress was neither ordered nor included in the care plan and was also set incorrectly. Staff confirmed the mattress issue had been overlooked, and one resident reported the bed was hard and uncomfortable.
The facility failed to implement enhanced barrier precautions (EBP) for 11 residents identified as having a higher risk of infections. Observations revealed no rooms with EBP signage, and staff interviews confirmed a lack of awareness and training on EBP. The Infection Preventionist admitted to waiting for corporate instructions to proceed with implementation, despite the facility's policy requiring EBP for residents with wounds or indwelling medical devices.
The facility failed to ensure that pharmacy recommendations were addressed by the physician in a timely manner for four residents, affecting the management of their medications. Interviews confirmed that the facility's policy required pharmacy recommendations to be addressed within 30 days, which was not adhered to.
The facility failed to implement necessary interventions to prevent skin breakdown for a resident with spina bifida and dementia. Despite physician's orders for palm shields and Prevalon boots, the resident was repeatedly observed without these devices, and staff were unsure about their necessity.
The facility failed to timely assess, treat, and report increased pain for a resident with a history of chronic pain and other medical conditions. Despite the resident's care plan indicating the need for immediate response to pain complaints, staff did not adhere to these guidelines, resulting in inadequate pain management. Observations and interviews revealed that the resident frequently cried out in pain, but staff did not assess the pain level, offer non-pharmacological interventions, or notify the physician.
The facility failed to ensure appropriate indications for prescribing antibiotics to three residents, as required by antibiotic stewardship protocols. Antibiotics were administered without conducting necessary diagnostic tests such as urinalysis and culture and sensitivity, despite residents exhibiting symptoms of UTIs.
Failure to Provide Proper Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide adequate notice for Medicare A benefits ending for skilled services and did not provide the right to appeal for three residents reviewed for Beneficiary Notices and termination of services. Review of the Notice of Medicare Non-Coverage notifications for Residents #98, #99, and #100 showed that Medicare coverage of therapy services was set to end, but each notice lacked a legal signature documenting that a verbal notice had been given. The Administrator verified that all three residents were not provided a minimum 48-hour notice for the end of benefits or appeals. Resident #98 was admitted with diagnoses including myocardial infarction, intestinal obstruction, lack of coordination, and muscle weakness, and the quarterly MDS showed minimally impaired cognition. Resident #99 was admitted with diagnoses including dementia, hypertension, lack of coordination, and muscle weakness, and the quarterly MDS showed severely impaired cognition. Resident #100 was admitted with diagnoses including gout, morbid obesity, schizophrenia, lack of coordination, and muscle weakness, and the quarterly MDS showed minimally impaired cognition. For each of these residents, the Medicare non-coverage notice indicated therapy coverage would end, but the notices did not include a legal signature with a statement that verbal notice had been given.
Incomplete PASARR Screening for Resident with Mood Disorder
Penalty
Summary
The facility failed to accurately complete a level one PASARR for Resident #32 and did not indicate mood disorder or other mental disorder on the serious mental illness section for review for a level two. Resident #32 was admitted on 03/27/2026 and had diagnoses including major depressive disorder, PTSD, and respiratory failure. The MDS 3.0 assessment dated [DATE] showed a BIMS score of 15 out of 15, indicating cognitive intactness, and also identified the resident as having a mood disorder and mental disorder. However, the PASARR completed on 03/27/2026 by the Social Services Director did not list mood disorder or other mental disorder under the level one review for serious mental illness. During interview on 04/15/2026 at 3:00 P.M., the Nurse Adm-Assistant Director and Nurse Adm-Director confirmed that mood disorder or other mental disorder was not included on the level one screen for the PASARR. The facility was unable to provide a policy for PASARRs.
Failure to Establish PICC Line Care Orders and Baseline Plan
Penalty
Summary
The facility failed to ensure a resident admitted with a PICC/IV access had a baseline plan of care and line maintenance orders in place upon admission. Resident #16 was admitted with diagnoses including acute and subacute infective endocarditis, psychoactive substance abuse, and muscle weakness, and the most recent MDS indicated the resident was cognitively intact and receiving IV antibiotic medication through an IV access. Review of the medical record showed no baseline plan of care for PICC access care. The physician orders dated on admission included instructions to flush the PICC per manufacturer guideline or protocol with 20 ml of 0.9% normal saline and 5 ml of 10 units/ml heparinized saline flush, but the record showed no PICC line maintenance orders on the admission date or the following day. Additional orders for 0.9% normal saline and heparinized saline flushes prior to and after medication administration were not entered until two days later, with a start date the next day. The TAR for the first three days after admission showed no PICC line maintenance care documented. Staff interviews confirmed the resident did not have PICC maintenance care upon admission until it was ordered later, and the DON verified there was no baseline care plan for the PICC care.
Pressure ulcer assessment and air mattress setting failures
Penalty
Summary
The facility failed to ensure timely pressure ulcer assessment and treatment for a resident admitted with spina bifida with hydrocephalus, paraplegia, muscle weakness, neuromuscular dysfunction of the bladder, and gastrostomy status. On admission, the resident had a reddened, non-blanchable lower back pressure injury with two open areas, but from admission until the wound CNP evaluated the resident a week later, there was no documentation of assessment, staging, wound bed description, or accurate measurements for the lower back areas. During that same period, there were no treatment orders or documented treatments for the lower back pressure ulcer areas, and staff later stated they had been using a sacrum treatment for the lower back areas even though the resident did not have a sacrum skin alteration. The facility also failed to ensure air mattresses were set to proper functional settings for two residents. One resident with stage 4 pressure ulcers, morbid obesity, diabetes, peripheral vascular disease, and total dependence for several activities had an air mattress ordered and care planned, but observations showed the mattress set at 550 pounds while the resident’s weight was 372.4 pounds, and the resident stated the bed was not comfortable and was really hard. Another resident with impaired mobility, heart failure, morbid obesity, and risk for skin breakdown had an air mattress in use, but there was no physician order for the mattress and it was not included in the care plan; observations showed the mattress set to alternate and 490 pounds while the resident’s weight was 413 pounds. For the resident with the lower back pressure injuries, the admission record and baseline care plan noted a pressure injury and an air mattress, but the clinical admission assessment did not include staging or complete wound details. The wound CNP later reviewed the areas and identified a stage IV pressure ulcer on the left lower back and a stage IV pressure ulcer on the right lower back, stating the hospital documentation indicated both areas were stage IV. For the resident whose mattress was not ordered or care planned, staff confirmed the air mattress had been overlooked. The facility policy required documentation of all services provided and objective observations and treatments performed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents when appropriate, affecting 11 residents identified as having a higher risk of infections. Observations over several days revealed that there were no rooms with signage indicating residents were on EBP. The residents identified included those with indwelling Foley catheters, dialysis ports, draining wounds, ostomies, and enteral feeding tubes. Interviews with various staff members, including a State Tested Nursing Assistant (STNA), Activity Director (AD), Infection Preventionist (IP), and Licensed Practical Nurse (LPN), confirmed that they were either unaware of EBP or had not received any education on them. The IP admitted to knowing about EBP but was waiting for instructions from the corporate office to proceed with implementation. The facility's policy on Enhanced Barrier Precautions stated that all staff would receive training on EBP, high-risk activities, and common organisms requiring EBP. The policy also required orders for EBP for residents with wounds or indwelling medical devices, even if they were not known to be infected or colonized with a multi-drug resistant organism (MDRO). Despite this policy, the facility had not implemented EBP, and staff were not provided with the necessary training or resources, such as gowns and gloves, to follow these precautions. This lack of implementation and education potentially affected all residents residing in the facility, which had a census of 90 at the time of the survey.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician in a timely manner for four residents. Resident #43 had a pharmacy recommendation for a gradual dose reduction of Lexapro, which was reviewed by the physician 35 days after the recommendation was made. Resident #78 had a pharmacy recommendation for a gradual dose reduction of melatonin, which was reviewed 48 days after the recommendation was made. Resident #77 had a pharmacy recommendation for a gradual dose reduction of Gabapentin, which was reviewed over 30 days after the recommendation was made. Resident #32 had a pharmacy recommendation to reevaluate the medicinal need of Dexilant, which was reviewed over 30 days after the recommendation was made. Interviews with the Regional Director of Clinical Operations confirmed that the facility's policy required pharmacy recommendations to be addressed by the physician no later than 30 days after they were made. The facility's failure to adhere to this policy affected the timely management of medications for the residents involved, all of whom had various medical conditions including end-stage renal disease, hypertension, psychosis, dementia, insomnia, protein-calorie malnutrition, Parkinson's disease, chronic lymphocytic leukemia, traumatic compartment syndrome, emphysema, anemia, metabolic encephalopathy, fracture of the right femur, chronic obstructive pulmonary disorder, depression, and anxiety.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions to prevent skin breakdown were implemented as appropriate for Resident #45, who had diagnoses including spina bifida, dementia with behavioral disturbance, and contractures of the left and right hand. The resident had physician's orders for the application of bilateral palm shields with finger separators and Prevalon boots to the bilateral lower extremities. However, during multiple observations, the resident was found without these prescribed devices in place. The palm shields were found stored in the resident's drawer instead of being used as ordered, and staff were unsure about the necessity of the Prevalon boots. The care plan for Resident #45 indicated the need for these interventions to prevent skin breakdown and potential injury. Despite this, the resident was repeatedly observed without the required palm shields and Prevalon boots. Interviews with staff confirmed the non-compliance with the physician's orders, indicating a failure to follow the care plan and implement necessary preventive measures. This deficiency was identified through medical record reviews, observations, and staff interviews, highlighting a lapse in the facility's adherence to its own policies and procedures for pressure ulcer prevention.
Failure to Timely Assess, Treat, and Report Increased Pain
Penalty
Summary
The facility failed to timely assess, treat, and report increased pain for Resident #65, who had a history of severe protein calorie malnutrition, bipolar disorder, chronic pain, peripheral vascular disease, carpal tunnel syndrome, polyneuropathy, PTSD, and a history of substance abuse. Despite the resident's care plan indicating the need for immediate response to pain complaints and regular evaluation of pain interventions, the facility did not adhere to these guidelines. The resident's pain was not adequately managed, and there was a lack of documentation and communication with the physician regarding the resident's increasing pain levels. Observations and interviews revealed that Resident #65 frequently cried out in pain and was visibly distressed. On multiple occasions, staff did not assess the resident's pain level, offer non-pharmacological interventions, or notify the physician about the resident's pain. For instance, on 05/05/24, the resident was observed crying in the common area, and the STNA did not inform the nurse. Similarly, on 05/06/24, the resident was seen crying out in pain, but the LPN did not address the resident or assess her pain. The facility's policy on pain assessment and management, which required comprehensive pain assessments and timely interventions, was not followed. The nursing progress notes lacked documentation of increased pain, physician notifications, and non-pharmacological interventions. Interviews with staff confirmed that the resident's pain had increased over the past few months, but appropriate actions were not taken to manage the pain effectively. The failure to adhere to the facility's pain management policy resulted in inadequate pain control for Resident #65.
Failure to Ensure Appropriate Indications for Antibiotic Use
Penalty
Summary
The facility failed to ensure appropriate indications for prescribing antibiotic medications to residents, affecting three residents reviewed for antibiotic stewardship. Resident #28 was prescribed Bactrim for a urinary tract infection (UTI) without a urinalysis or culture and sensitivity test, despite exhibiting symptoms such as new or worsening incontinence and increased urgency. The infection preventionist confirmed that the resident did not meet surveillance criteria and should have had further diagnostic testing before receiving the antibiotic. Similarly, Resident #62 was prescribed Macrobid for a UTI based on symptoms of confusion and acute dysuria without any diagnostic testing. The infection preventionist also confirmed that this resident did not meet surveillance criteria and required a urinalysis and culture and sensitivity test before antibiotic administration. Resident #50 was prescribed Bactrim for a UTI based on symptoms of acute dysuria and increased urgency, with a positive dip test for nitrates. However, no urinalysis or culture and sensitivity test was conducted to ensure the correct medication was administered. The infection preventionist confirmed that this resident, like the others, did not meet surveillance criteria and should have undergone further diagnostic testing. These actions indicate a failure by the facility to ensure appropriate indications for antibiotic use, as required by antibiotic stewardship protocols.
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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 Lucasville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Manor Of Lucasville Ii | 0.8 mi | ★★★★★ | 0 | 0 |
| Rest Haven Nursing Home | 6.2 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Rosemount Pavilion | 8.9 mi | ★★★★★ | 3 | 0 |
| The Pavilion At Piketon | 9.4 mi | ★★★★★ | 0 | 0 |
| Piketon Nursing Center | 10.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.