Clarksville, IN

Wedgewood Healthcare Center

1-star overall rating with 2-star inspections with $63,440 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

101 Potters Ln, Clarksville, IN

(812) 948-0808

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

124

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Communicare Health

Operator or chain grouping

Approved since

1985-11-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

122 facilities

Chain averages 3 overall / 2 health / 2 staffing / 4 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

0.33

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.01

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.22

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.21

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.99

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.23

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.35

CMS adjusted RN staffing hours

Adjusted total hours

3.42

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,240

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

Performance score

30.31

Composite VBP score used to determine payment impact.

Payment multiplier

0.9859

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

4.44

Baseline 7.40% · Performance 6.51% · Measure score 4.44 · Achievement 4.44 · Improvement 3.20

Total nurse turnover

4.19

Baseline 79.81% · Performance 54.02% · Measure score 4.19 · Achievement 2.36 · Improvement 4.19

Adjusted total nurse staffing

0.46

Baseline 2.76 hours · Performance 3.05 hours · Measure score 0.46 · Achievement 0 · Improvement 0.46

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.42%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 59 · Observed rate 10.17% · Lower 95% interval 7.07%
Discharge to community	38.58%	50.57% 12 pts worse	No Different than the National Rate · Eligible stays 49 · Observed rate 24.49% · Lower 95% interval 23.97%
Medicare spending per beneficiary	1.1	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 37 · Denominator 37
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 37
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	5.41%	2.29% 3.1 pts worse	Numerator 2 · Denominator 37 · Adjusted rate 4.38%
Healthcare-associated infections requiring hospitalization	6.51%	7.12% 0.6 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 2.96%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 160
Staff flu vaccination coverage	51.72%	42% 9.7 pts better	Numerator 45 · Denominator 87
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 19 · 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	Not Available	25.2%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.8	1.6 0.8 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	1.5 0.9 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	86.5%	93.6% 7.1 pts worse	93.4% 6.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 67.7% · Q2 90.3% · Q3 94.7% · Q4 93.3% · 4Q avg 86.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.0%	95.4% 2.6 pts better	95.5% 2.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.4%	3.8% 2.4 pts better	3.3% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	14.6%	24.6% 10 pts better	11.4% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 13.1% · Q3 9.0% · Q4 16.5% · 4Q avg 14.6%
Percentage of long-stay residents who lose too much weight	2.2%	5.6% 3.4 pts better	5.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.9% · Q3 1.4% · Q4 1.2% · 4Q avg 2.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.8%	23.5% 2.3 pts worse	19.6% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 22.9% · Q3 27.1% · Q4 26.8% · 4Q avg 25.8%
Percentage of long-stay residents who received an antipsychotic medication	17.0%	14.8% 2.2 pts worse	16.7% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 11.8% · Q3 15.3% · Q4 17.9% · 4Q avg 17.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	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	4.6%	13.3% 8.7 pts better	16.3% 11.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 7.7% · Q3 0.0% · Q4 2.2% · 4Q avg 4.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	2.8%	11.7% 8.9 pts better	14.9% 12.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.3% · Q3 3.7% · Q4 2.5% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.4% 0.4 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.8%	1.2% 0.4 pts better	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.8%	24.2% 2.4 pts better	19.8% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 31.7% · Q3 13.9% · Q4 21.8% · 4Q avg 21.8%
Percentage of long-stay residents with pressure ulcers	4.3%	4.1% 0.2 pts worse	5.1% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.8% · Q3 4.9% · Q4 2.5% · 4Q avg 4.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	57.2%	81.6% 24.4 pts worse	81.7% 24.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 67.3% · Q2 79.2% · Q3 53.2% · Q4 31.5% · 4Q avg 57.2%
Percentage of short-stay residents who had an outpatient emergency department visit	18.0%	10.5% 7.5 pts worse	12.0% 6 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 19.2% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.4%	79.0% 6.4 pts better	79.7% 5.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	39.3%	22.4% 16.9 pts worse	23.9% 15.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 39.3% · Observed 38.5% · Expected 23.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-26 · Fire 2025-09-26

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2024-08-12 · Fire 2024-08-12

11 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-06-21 · Fire 2023-06-21

19 health deficiencies

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

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-09-26

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2026-01-12

E · Potential for more than minimal harm 2025-09-26

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2026-02-19

E · Potential for more than minimal harm 2025-09-26

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 2026-01-12

E · Potential for more than minimal harm 2025-09-26

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2026-01-12

E · Potential for more than minimal harm 2025-09-26

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2026-02-19

E · Potential for more than minimal harm 2025-09-26

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2026-01-12

F · Potential for more than minimal harm 2024-08-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-09-23

E · Potential for more than minimal harm 2024-08-12

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-09-23

E · Potential for more than minimal harm 2024-08-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-08-12

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-08-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-23

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-18

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-12-01

D · Potential for more than minimal harm 2025-09-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-11-24

D · Potential for more than minimal harm 2025-09-26

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 2025-11-24

D · Potential for more than minimal harm 2025-09-26

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-11-24

D · Potential for more than minimal harm 2025-09-26

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-11-24

D · Potential for more than minimal harm 2025-09-26

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-11-24

D · Potential for more than minimal harm 2024-11-15

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-15

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-08-12

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-09-23

E · Potential for more than minimal harm 2024-08-12

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 2024-09-23

D · Potential for more than minimal harm 2024-08-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-08-12

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-08-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-23

E · Potential for more than minimal harm 2024-07-26

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-08-23

D · Potential for more than minimal harm 2024-07-26

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-08-23

D · Potential for more than minimal harm 2024-07-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-23

D · Potential for more than minimal harm 2024-03-20

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-04-08

D · Potential for more than minimal harm 2023-09-18

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-09-19

J · Immediate jeopardy 2023-06-21

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-07-17

E · Potential for more than minimal harm 2023-06-21

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2023-07-17

E · Potential for more than minimal harm 2023-06-21

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-07-17

E · Potential for more than minimal harm 2023-06-21

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 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

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 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-06-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-07-17

E · Potential for more than minimal harm 2023-04-05

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-04-05

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-04-05

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 2023-04-21

D · Potential for more than minimal harm 2023-04-05

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-04-21

Penalties and ownership

What sits behind the stars

$63,440 2023-06-21

Fine

Fine · fine $63,440

Fine

Ownership

Adams County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 52 facilities 2023-12-01

Adams County Memorial Hospital

Operational/Managerial Control · Organization

0% 52 facilities 2023-12-01

Borne-Bauman, Candice