6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cincinnati, OH
5-star overall rating with 4-star inspections with 6 recent health deficiencies
4400 Glen Este Withamsville Road, Cincinnati, OH
(513) 752-3710
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
175
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carespring
Operator or chain grouping
Approved since
1990-02-01
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
RN hours / resident day
0.78
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.58
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.81
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
4,495
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9927
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.69
Baseline 24.35% · Performance 21.28% · Measure score 3.69 · Achievement 0 · Improvement 3.69
Healthcare-associated infections
3.83
Baseline 11.09% · Performance 8.45% · Measure score 3.83 · Achievement 0 · Improvement 3.83
Total nurse turnover
5.45
Baseline 45.60% · Performance 41.42% · Measure score 5.45 · Achievement 5.45 · Improvement 1.51
Adjusted total nurse staffing
2.93
Baseline 2.61 hours · Performance 3.7 hours · Measure score 2.93 · Achievement 2.19 · Improvement 2.93
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 16.64% |
10.72%
5.9 pts worse
|
Worse than the National Rate · Eligible stays 272 · Observed rate 21.32% · Lower 95% interval 13.65% |
| Discharge to community | 49.98% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 225 · Observed rate 44.89% · Lower 95% interval 43.02% |
| 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 148 · Denominator 148 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 148 |
| Discharge self-care score | 56.96% |
53.69%
3.3 pts better
|
Numerator 45 · Denominator 79 |
| Discharge mobility score | 46.84% |
50.94%
4.1 pts worse
|
Numerator 37 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 148 · Adjusted rate 0.66% |
| Healthcare-associated infections requiring hospitalization | 8.45% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 9.59% · Lower 95% interval 5.59% |
| Staff COVID-19 vaccination coverage | 0.43% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 235 |
| Staff flu vaccination coverage | 14.88% |
42%
27.1 pts worse
|
Numerator 50 · Denominator 336 |
| Discharge function score | 56.96% |
56.45%
0.5 pts better
|
Numerator 45 · Denominator 79 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 88 · Denominator 88 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 27.85% |
25.2%
2.7 pts better
|
Numerator 22 · Denominator 79 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
92.4%
5.7 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.4% · Q3 97.5% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.5%
4 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.3%
2.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 89.0% |
26.1%
62.9 pts worse
|
11.4%
77.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.8% · Q2 93.3% · Q3 86.7% · Q4 90.2% · 4Q avg 89.0% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.2%
0.6 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.2% · Q3 6.1% · Q4 8.0% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
25.4%
5.1 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 24.3% · Q3 17.5% · Q4 16.8% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.1% |
11.5%
9.4 pts better
|
16.7%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 2.4% · Q4 3.4% · 4Q avg 2.1% · 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 | 2.1% |
7.7%
5.6 pts better
|
16.3%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.3% · Q4 2.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.8% |
6.2%
5.4 pts better
|
14.9%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.2% · 4Q avg 0.8% · 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 | 27.5% |
21.7%
5.8 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 29.1% · Q3 24.4% · Q4 27.0% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
3.7%
2.7 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.0% · Q3 0.5% · Q4 0.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
78.1%
21.8 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
12.5%
4.2 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.7% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.1% |
75.6%
16.5 pts better
|
79.7%
12.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
25.1%
2.6 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 22.3% · Expected 23.6% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
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 2022-05-24
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-05-24
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-05-24
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-05-24
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-05-24
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-05-24
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-05-24
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 2022-05-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-05-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-08-13
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-13
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-08-13
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-08-13
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-08-13
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-08-13
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-22
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-22
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-22
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-05-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-24
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-08-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-08-13
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
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