Cycle 1
Health 2025-02-14 · Fire 2025-02-14
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
West Chester, OH
Chesterwood Village
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
8073 Tylersville Road, West Chester, OH
(513) 777-1400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
119
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carespring
Operator or chain grouping
Approved since
1996-06-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 4 health / 3 staffing / 5 quality stars
Changed ownership
No
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
0.57
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,573
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.51% · Performance 24.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.20% · Performance 8.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.66
Baseline 72.26% · Performance 62.00% · Measure score 1.66 · Achievement 0 · Improvement 1.66
Adjusted total nurse staffing
2.99
Baseline 3.86 hours · Performance 3.93 hours · Measure score 2.99 · Achievement 2.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.67% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 450 · Observed rate 10.67% · Lower 95% interval 9.22% |
| Discharge to community | 65.98% |
50.57%
15.4 pts better
|
Better than the National Rate · Eligible stays 436 · Observed rate 64.22% · Lower 95% interval 62.46% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 296 · Denominator 296 |
| Falls with major injury | 0.34% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 296 |
| Discharge self-care score | 57.28% |
53.69%
3.6 pts better
|
Numerator 59 · Denominator 103 |
| Discharge mobility score | 67.96% |
50.94%
17 pts better
|
Numerator 70 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 4 · Denominator 296 · Adjusted rate 1.09% |
| Healthcare-associated infections requiring hospitalization | 8.78% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 274 · Observed rate 8.39% · Lower 95% interval 5.96% |
| Staff COVID-19 vaccination coverage | 0.55% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 181 |
| Staff flu vaccination coverage | 30.81% |
42%
11.2 pts worse
|
Numerator 114 · Denominator 370 |
| Discharge function score | 74.76% |
56.45%
18.3 pts better
|
Numerator 77 · Denominator 103 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 175 · Denominator 175 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 89 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 22.38% |
25.2%
2.8 pts worse
|
Numerator 32 · Denominator 143 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
94.5%
0.4 pts better
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.3%
1.9 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 8.0% · Q3 4.1% · Q4 2.7% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 58.7% |
26.1%
32.6 pts worse
|
11.4%
47.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 53.3% · Q3 67.2% · Q4 81.4% · 4Q avg 58.7% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
6.2%
0.9 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 5.3% · Q3 5.6% · Q4 3.6% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
25.4%
2.8 pts better
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 21.1% · Q3 22.2% · Q4 22.8% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
11.5%
4 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 11.4% · Q3 8.7% · Q4 4.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
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 | 3.6% |
7.7%
4.1 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
6.2%
0.7 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 3.6% · Q3 5.8% · Q4 5.5% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 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 | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 31.3% |
21.7%
9.6 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 27.5% · Q3 17.7% · Q4 46.3% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
3.7%
0.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.1% · Q3 3.9% · Q4 4.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
78.1%
21.7 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
12.5%
About the same
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.1% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.0% · Q3 0.5% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
75.6%
11.5 pts better
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
25.1%
3.5 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 26.0% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-05 · Fire 2022-07-05
2 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-14
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-03-17
F · Potential for more than minimal harm
2022-07-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-07-05
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-07-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-07-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-07-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-07-05
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-07-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-07-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-07-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-07-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-07-05
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-07-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-07-22
F · Potential for more than minimal harm
2019-10-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-19
F · Potential for more than minimal harm
2019-10-10
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2019-11-19
F · Potential for more than minimal harm
2019-10-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-11-19
E · Potential for more than minimal harm
2019-10-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-11-19
E · Potential for more than minimal harm
2019-10-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-11-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-14
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 2025-03-17
D · Potential for more than minimal harm
2025-02-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-14
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 2025-03-17
D · Potential for more than minimal harm
2024-03-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-02
E · Potential for more than minimal harm
2023-07-05
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
2023-05-11
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 2023-05-23
C · Minimal harm
2023-05-11
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-05-23
E · Potential for more than minimal harm
2022-07-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-22
E · Potential for more than minimal harm
2019-10-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2019-11-19
E · Potential for more than minimal harm
2019-10-10
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 2019-11-19
D · Potential for more than minimal harm
2019-10-10
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 2019-11-19
D · Potential for more than minimal harm
2019-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-19
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Heritagespring Healthcare Center Of West Chester
West Chester, OH
3-star overall rating with 3-star inspections with $40,745 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Mcv Health Care Facilities, Inc
Mason, OH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of Cedar Village.
Mason, OH
3-star overall rating with 2-star inspections with $73,281 in total fines with 13 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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