Above 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 Edgewood Manor Of Wellston during CMS and state inspections, most recent first.
A resident with multiple diagnoses and impaired cognition was admitted with hospital instructions to receive 12.5 mg of metoprolol twice daily, but due to a transcription error, was administered 25 mg twice daily. The DON confirmed the discrepancy between the hospital discharge instructions and the physician's order. No adverse effects were documented.
Two residents had PRN hydroxyzine orders left active beyond the 14-day limit without being re-ordered by the physician or discontinued. One resident had anxiety, depression, and impaired cognition, and the other had dementia, bipolar disorder, MDD, anxiety, schizophrenia, and intact cognition. The DON confirmed both PRN orders remained active longer than allowed.
Missing PTSD Care Plan: A resident with PTSD, depression, anxiety, bipolar disorder, and schizoaffective disorder had no active care plan addressing PTSD triggers despite prior documentation of trauma related to the loss of her daughter. The resident had intact cognition and was receiving multiple psychotropic and pain-related meds, but the current care plan did not include PTSD-related interventions or triggers, and staff could not explain the conflicting care plan dates.
A resident with multiple chronic conditions, including dementia and bilateral cataracts, was seen by optometry and found to have visually significant age-related cataracts. The optometry exam recommended a cataract evaluation with an ophthalmologist, but the record showed no ophthalmology referral or visit had been arranged, and SSD confirmed no appointment had been made.
Failure to complete neuro checks after an unwitnessed fall. A resident with severe cognitive impairment and multiple fall-risk diagnoses was found sitting on the floor mat beside his bed after an unwitnessed fall. Staff documented that he was alert, smiling, and without visible injury, but neuro checks were not completed even though nursing staff and the DON confirmed they are required after unwitnessed falls. The fall was later documented as unwitnessed, despite staff initially being told it was witnessed.
A resident with severe cognitive impairment and a history of falls experienced unrelieved pain due to a fractured hip. Despite clear signs of distress, the LTC facility delayed administering prescribed pain medication for nearly five hours and failed to conduct a comprehensive pain assessment or implement non-pharmacological interventions. Interviews revealed a lack of communication and action among staff, and the facility's pain management policy was not followed.
The facility failed to accurately complete MDS assessments for two residents, omitting critical information about their treatments. One resident's assessment did not include hemodialysis, despite it being a part of their treatment plan. Another resident's assessment failed to list multiple psychotropic medications prescribed for their mental health conditions. These omissions were confirmed by the DON.
A facility failed to update a PASARR for a resident who received a new diagnosis of schizophrenia. The resident was admitted with several diagnoses, and the new diagnosis was not reflected in the PASARR. The social worker responsible was unaware of the change, and the facility lacked a PASARR policy.
A facility failed to ensure accurate PASARR documentation for a resident with multiple mental health diagnoses. The PASARR listed only one diagnosis and omitted several psychotropic medications the resident was prescribed. The DON confirmed the PASARR was incomplete.
The facility failed to create comprehensive care plans for two residents with mental health conditions. One resident with schizophrenia had no care plan addressing this diagnosis, confirmed by the DON. Another resident with PTSD had no care plan detailing triggers or interventions, as confirmed by social services and nursing assistants. Both cases highlight a lack of proper documentation and awareness among staff.
A resident with a history of cerebral infarction and muscle contracture was not provided with bilateral palm protectors as required by their care plan and physician's orders. Observations over several days showed the resident without the protectors and not receiving prescribed hygiene and range of motion exercises. An LPN confirmed the absence of the protectors, suggesting they might be in the laundry.
A facility failed to ensure proper orders and care plan interventions for a resident's dialysis care. The resident, with end-stage renal disease, had no specific interventions for the care of their AV fistula dressing. Staff interviews revealed a lack of guidance on handling the dressing if it became soiled or detached, contrary to facility policy requiring documentation and intervention by a licensed nurse.
A facility failed to assess and address a resident's PTSD, despite the resident having multiple diagnoses including PTSD. The care plan lacked documentation for managing PTSD, and staff were unaware of the resident's condition, triggers, or interventions. The facility's policy required staff training on trauma, but this was not evident in the care provided.
A facility failed to provide necessary behavioral health care for a resident with major depressive disorder. Despite symptoms being noted in the MDS assessment, no care plan or specific target behaviors were identified. Interviews with an LPN and the DON confirmed the lack of documentation and assessment for the resident's depressive symptoms.
A resident was administered chemotherapy medication in error due to the facility's failure to verify medication orders and include the resident in an admission care plan meeting. This resulted in increased weakness, pain, nausea, constipation, and weight loss for the resident.
The facility failed to ensure residents were free from unnecessary medications, affecting two residents. Both residents had orders for multiple pain medications without parameters to guide administration based on pain levels. Interviews with LPNs revealed inconsistent practices, and the DON confirmed the lack of parameters.
Failure to Accurately Implement Discharge Medication Orders
Penalty
Summary
The facility failed to accurately implement discharge medication orders for a resident who was admitted with diagnoses including hypertension, diabetes mellitus, and adult failure to thrive, and who was assessed to have impaired cognition. Hospital discharge instructions specified that the resident should continue taking one half of a 25 mg metoprolol tablet (12.5 mg) twice daily. However, upon admission, the physician's order was transcribed incorrectly, resulting in the resident receiving one whole 25 mg tablet twice daily. Review of records confirmed this discrepancy, and staff interview with the DON verified that the hospital's instructions were not followed as written. There was no documentation of adverse effects from the medication error.
PRN Psychotropic Orders Left Active Beyond 14 Days
Penalty
Summary
The facility failed to ensure as-needed psychotropic medications were not prescribed for longer than 14 days without being re-ordered by the physician or discontinued. During the annual survey, record review and staff interview identified this issue in two of five residents reviewed for unnecessary medications, out of a census of 40. Resident #37 was admitted with diagnoses including anxiety disorder, depression, and acute respiratory failure with hypoxia, and the admission MDS dated 05/23/25 showed impaired cognition. A physician order dated 05/27/25 directed hydroxyzine 25 mg every 24 hours as needed, but the order did not include a stop date and remained active until 06/27/25, 31 days after it was ordered. Resident #42 was admitted with diagnoses including dementia, bipolar disorder, major depressive disorder, anxiety disorder, and schizophrenia, and the quarterly MDS dated 07/10/25 showed intact cognition. A physician order dated 03/29/25 directed hydroxyzine 25 mg every 12 hours as needed, but it also had no stop date and was not discontinued until 05/01/25, 33 days after it was ordered. The DON confirmed on 09/04/25 at 10:05 A.M. that both as-needed hydroxyzine orders were active for longer than 14 days without being discontinued or re-ordered by the physician.
Missing PTSD Care Plan
Penalty
Summary
The facility failed to ensure a care plan was in place for a resident with a diagnosis of PTSD. Resident #3 was admitted on 09/10/2024 and later re-entered the facility on 04/08/2025. The resident’s diagnoses included major depressive disorder, anxiety disorder, bipolar disorder, PTSD, and schizoaffective disorder. The quarterly MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition for daily decision-making, and the resident was receiving antianxiety, antidepressant, opioid, and anticonvulsant medications daily. Trauma assessments completed on 09/11/24, 04/08/25, and 07/15/25 confirmed the PTSD diagnosis. Review of the resident’s prior care plan showed it had addressed trauma related to the loss of her daughter, with reported triggers including certain songs, shows, seeing her grandkids, crying children, signs of stress, and withdrawal from social situations. That care plan had a closed-out date of 04/15/2025 and a resolved date of 04/08/2025, with a revision date of 04/28/2025 noted on the resolved plan. The current care plan contained no active PTSD-related plan or triggers, and a later care plan dated 09/02/2025 was noted by Social Worker #153. During interview, Social Worker #153 and Regional Nurse #188 stated the prior PTSD care plan had not actually been resolved and could not explain why the old plan showed a resolve date or why a new PTSD care plan was initiated later.
Failure to Arrange Ophthalmology Referral for Resident with Visually Significant Cataracts
Penalty
Summary
The facility failed to ensure a timely referral appointment was made with ophthalmology for Resident #11, affecting one of two residents reviewed for communication and sensory. Resident #11 was readmitted on 04/10/25 with diagnoses including heart failure, chronic obstructive pulmonary disorder, atrial fibrillation, diabetes mellitus type two, peripheral vascular disease, dementia, and bilateral cataracts. The physician orders included ancillary services per 360 as needed on 04/11/25 and artificial tears ophthalmic solution 1% one drop in both eyes three times daily on 04/14/25. The quarterly MDS indicated the resident was cognitively intact with delusions and rejection of care and required minimal assistance with activities of daily living. Nursing progress notes showed the resident was seen by Optometry 360 on 04/14/25, and the vision exam documented combined forms of age-related cataracts bilaterally that were visually significant, with a recommendation to schedule a cataract evaluation with an ophthalmologist of facility choice. A later note stated the resident requested to be seen by Optometry 360 again, but was unable to be seen because it was too soon since the last visit. The medical record did not include evidence that the resident was referred to or seen by an ophthalmologist as of 09/04/25, and the Social Service Designee confirmed no ophthalmology appointment had been made.
Failure to Complete Neuro Checks After an Unwitnessed Fall
Penalty
Summary
A resident with senile degeneration of the brain, peripheral vascular disease, restlessness and agitation, and bilateral optic atrophy experienced an unwitnessed fall in his room after being found sitting on the floor mat beside his bed. His quarterly MDS showed a BIMS score of 03 out of 15, indicating severely impaired cognition, and he was dependent on staff assistance for bed mobility. The care plan identified fall risk related to poor safety awareness, confusion, poor communication comprehension, incontinence, and psychoactive drug use, with interventions including keeping the bed low and the call light within reach. After the fall, staff documented that the resident was alert, smiling, and without visible injury, and vital signs were obtained. However, the record showed that neuro checks were not completed after the unwitnessed fall. Nursing documentation later stated that neuro checks would be started, but interviews with nursing staff and the DON confirmed that neuro checks were required for unwitnessed falls and were not completed for this incident because incorrect information was received that the fall had been witnessed. The facility policy identified falls as witnessed or unwitnessed events.
Failure to Provide Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and necessary pain management for a resident, identified as Resident #23, who was severely cognitively impaired. On the date of the incident, the resident exhibited increased incontinence and both verbal and non-verbal signs of pain, such as facial grimacing and grabbing his right leg. Despite these clear indicators of distress, the nursing staff delayed administering the prescribed pain medication, Ultram, for nearly five hours after receiving the order. During this time, there was no evidence of a comprehensive pain assessment or attempts at non-pharmacological pain interventions. The resident's medical record indicated a history of repeated falls and vascular dementia, with a new diagnosis of a fractured right hip. The resident was admitted with a physician's order for Acetaminophen as needed for pain, but there was no documentation of its administration on the day of the incident. The nursing progress notes lacked any record of a fall or injury prior to the incident, and there was no documentation of pain assessment or management until the late afternoon when Ultram was finally administered. Interviews with the nursing staff revealed a lack of communication and action regarding the resident's pain. The RN assigned to the resident's care did not recall implementing any non-pharmacological interventions, and the STNAs reported the resident's pain to the RN multiple times without any immediate action taken. The Director of Nursing confirmed that a pain assessment should have been completed and acknowledged the failure to provide timely and effective pain management. The facility's policy on pain assessment and management was not followed, resulting in the resident being transferred to the emergency room for treatment of a fractured hip.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical needs and treatments. Resident #26, who was admitted with multiple diagnoses including muscle weakness, cognitive communication deficit, and end-stage renal disease, was receiving hemodialysis. However, the MDS assessment dated 06/20/24 did not include this critical treatment, despite the resident having started dialysis on 08/01/23. This omission was confirmed during an interview with the Director of Nursing and the MDS Coordinator. Similarly, Resident #15's MDS assessment was incomplete, failing to list the psychotropic medications prescribed for their conditions, which included schizoaffective disorder, bipolar disorder, and anxiety. The resident was receiving multiple medications for these diagnoses, such as Venlafaxine, Fluoxetine, and Clonazepam, among others. The Director of Nursing confirmed that the MDS did not reflect these medications, indicating a lack of comprehensive documentation of the resident's treatment plan.
Failure to Update PASARR with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to submit a resident review (RR) for a resident who received a new diagnosis of schizophrenia. The resident was admitted with multiple diagnoses, including acute myocardial infarction, urinary tract infection, metabolic encephalopathy, type II diabetes, anemia, cognitive communication disorder, anxiety disorder, and major depressive disorder. A new diagnosis of schizophrenia was added, but the PASARR did not reflect this change. The social worker responsible for completing PASARRs had not yet completed any and was unaware of the new diagnosis. The facility did not have a PASARR policy in place.
Inaccurate PASARR Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Pre Admission Screening and Resident Review (PASARR) for a resident upon admission. The resident, who was admitted with multiple mental health diagnoses including schizoaffective disorder, bipolar disorder, anxiety, PTSD, and borderline personality disorder, was found to have discrepancies in their PASARR documentation. The PASARR inaccurately listed only one mental health diagnosis, mood disorder, and failed to document the psychotropic medications the resident was receiving. Upon review, it was noted that the resident was prescribed several psychotropic medications for their mental health conditions, including Venlafaxine, Fluoxetine, Lumateperone Tosylate, Galantamine Hydrobromide, Carbamazepine, Brexpiprazole, Quetiapine Furmarate, Hydroxyzine Pamoate, and Clonazepam. The Director of Nursing confirmed that the PASARR was incomplete and did not reflect the resident's full list of mental health diagnoses or the psychotropic medications documented in the medical chart.
Failure to Develop Comprehensive Care Plans for Mental Health Conditions
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents with specific mental health diagnoses. Resident #17, who was admitted with multiple diagnoses including schizophrenia, did not have a care plan addressing this condition. Despite the diagnosis being added on 06/11/24, a review of the care plan dated 06/27/24 showed no evidence of goals or interventions for schizophrenia. The Director of Nursing confirmed the absence of a care plan for this condition during an interview. Similarly, Resident #15, who had a history of PTSD among other mental health conditions, did not have a care plan addressing PTSD. The resident's medical records and trauma-informed care assessment indicated symptoms related to PTSD, such as nightmares and feeling detached. However, the care plan dated 01/20/24 and updated on 06/12/24 lacked any mention of PTSD triggers or interventions. Interviews with social services and nursing assistants revealed a lack of awareness and documentation regarding the resident's PTSD, confirming the deficiency in care planning.
Failure to Provide Required Palm Protectors for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #10, was provided with the necessary bilateral palm protectors to prevent a decrease in their limited range of motion. The resident, who has a history of cerebral infarction, major depressive disorder, unspecified dementia, and muscle contracture, was observed multiple times over several days without the required palm protectors in place. The resident's care plan and physician's orders specified that the palm protectors should be worn at all times except during hygiene and range of motion exercises, yet these were not adhered to during the observations. Interviews and observations confirmed that the resident was not receiving the prescribed hygiene and range of motion exercises, and the palm protectors were not in use. An LPN acknowledged the absence of the palm protectors and suggested they might be in the laundry, offering to use washcloths as a temporary measure. The facility's policy on assistive devices and equipment requires staff to assist and supervise residents as needed, which was not followed in this case, leading to the deficiency.
Deficiency in Dialysis Care Planning
Penalty
Summary
The facility failed to ensure proper orders and care plan interventions were in place for a resident requiring dialysis care. Specifically, for Resident #26, who was admitted with multiple diagnoses including end-stage renal disease and chronic kidney disease stage 4, there was a lack of intervention for the care and condition of the dressing on the resident's left arm arteriovenous (AV) fistula. The physician's order only instructed the removal of the bandage at night after dialysis sessions on specific days, without any guidance on what to do if the dressing became soiled or detached before the scheduled removal. Interviews with facility staff, including an LPN and the Assistant Director of Nursing (ADON), revealed that there were no specific orders or care plan interventions for the dressing care of the AV fistula site. The LPN indicated that in the event of bleeding or contamination, she would reapply the dressing but would need to call the doctor for verification due to the absence of an order. The ADON confirmed the lack of orders and care plan interventions and stated that clarification would be sought. The facility's policy on Hemodialysis Access Care required documentation of the dressing's condition every shift and mandated that a licensed nurse change the dressing if it became wet, dirty, or not intact.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to appropriately assess and address the needs of a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including schizoaffective disorder, bipolar disorder, anxiety, PTSD, and others, was cognitively intact and independent with activities of daily living. Despite having a Trauma Informed Care assessment indicating the resident experienced nightmares and was constantly on guard, the facility did not document any plan for managing PTSD in the resident's care plan. Nursing progress notes lacked documentation related to PTSD, and the plan of care did not include any strategies for addressing PTSD. Interviews with facility staff, including an LPN, social services, and STNAs, revealed a lack of awareness and knowledge regarding the resident's PTSD, triggers, or interventions. The staff confirmed that this information should have been included in the resident's care plan or kardex. The Director of Nursing also confirmed the absence of identified triggers or interventions for the resident's PTSD. The facility's policy on Trauma Informed Care indicated that staff were to be trained on trauma, its impact, and strategies to address triggers, but this was not reflected in the care provided to the resident.
Failure to Address Major Depressive Disorder in Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with major depressive disorder. The resident, who was cognitively intact with a BIMS score of 13 out of 15, exhibited symptoms of depression such as little interest or pleasure in activities, feeling down, and trouble sleeping. Despite these symptoms being noted in the Minimum Data Set (MDS) assessment, the facility did not have an active care plan addressing the major depressive disorder, nor did they identify specific target behaviors related to the diagnosis. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the lack of documentation and assessment for the resident's depressive symptoms. The LPN acknowledged the resident's mood changes but was unsure if these were related to the depression diagnosis, while the Director of Nursing verified that no assessment or care plan had been initiated for the resident's major depressive disorder. This oversight indicates a failure to adequately address and manage the resident's behavioral health needs.
Failure to Ensure Resident Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure Resident #22 was free from significant medication errors, resulting in the administration of chemotherapy medication in error. Resident #22 was admitted with multiple diagnoses, including a history of liver and esophageal cancer, both of which were in remission. Despite this, the facility administered Capecitabine, a chemotherapy medication, from 11/27/23 through 01/29/24 without proper verification of the medication orders from the referring hospital or the Veterans Affairs (VA). This led to Resident #22 experiencing increased weakness, pain, nausea, constipation, and weight loss. The facility did not include Resident #22 in an admission care plan meeting, which would have allowed for a review of the baseline care plan, medication list, and setting of goals for his stay. The medication administration records (MAR) showed that Capecitabine was administered continuously without the required seven-day break, further indicating a lack of proper medication management. Interviews with staff revealed that there was a failure to clarify unclear medication orders with the hospital or the in-house physician, and the error was only discovered after Resident #22 was discharged and the VA reviewed his discharge information. Resident #22 reported that his chemotherapy medication had been discontinued approximately seven years ago and was unaware of the medications he was receiving at the facility. The Director of Nursing (DON) and other staff confirmed that the baseline care plan meeting did not include Resident #22 or his family, and the medication reconciliation process was not properly followed. This lack of communication and verification led to the administration of an unnecessary and harmful medication, causing significant adverse effects for Resident #22.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications, affecting two residents. Resident #33, who had multiple diagnoses including atrial fibrillation and acute kidney failure, had orders for both tramadol and Tylenol for pain management. However, there were no parameters in place to determine which PRN pain medication should be administered based on the numerical level of pain reported by the resident. Similarly, Resident #44, with diagnoses including ataxic cerebral palsy and schizophrenia, had orders for acetaminophen and hydrocodone-acetaminophen for pain, but also lacked parameters to guide the administration of these medications based on pain levels. Interviews with three LPNs revealed inconsistent practices in determining which pain medication to administer, with decisions often based on subjective assessments or resident input. The Director of Nursing confirmed that there were no parameters in place for these residents and stated that pain medication should be given based on the resident's reported pain level and physician's orders. The facility's policy on administering medications emphasized the need to follow prescriber's orders and to contact the prescriber if a dosage is believed to be inappropriate or excessive.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wellston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jenkins Care Community | 2.4 mi | ★★★★★ | 1 | 0 |
| Four Winds Nursing Facility | 4.3 mi | ★★★★★ | 2 | 0 |
| Maple Hills Skilled Nursing & Rehabilitation | 10.7 mi | ★★★★★ | 2 | 0 |
| Ayden Healthcare Of Jackson | 12.1 mi | ★★★★★ | 0 | 0 |
| National Church Residences Bristol Village | 23.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.