Cycle 1
Health 2025-11-19 · Fire 2025-11-19
3 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
West Chester, OH
Heritagespring Healthcare Center Of West Chester
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
7235 Heritagespring Drive, West Chester, OH
(513) 759-5777
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carespring
Operator or chain grouping
Approved since
2004-10-07
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
0.79
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,309
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.20% · Performance 22.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.49
Baseline 7.51% · Performance 6.49% · Measure score 4.49 · Achievement 4.49 · Improvement 3.54
Total nurse turnover
0
Baseline 62.59% · Performance 73.10% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.43
Baseline 2.61 hours · Performance 3.54 hours · Measure score 2.43 · Achievement 1.63 · Improvement 2.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.94% |
10.72%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 194 · Observed rate 16.49% · Lower 95% interval 10.21% |
| Discharge to community | 48.2% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 170 · Observed rate 43.53% · Lower 95% interval 41.63% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 116 · Denominator 116 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 116 |
| Discharge self-care score | 51.56% |
53.69%
2.1 pts worse
|
Numerator 33 · Denominator 64 |
| Discharge mobility score | 54.69% |
50.94%
3.8 pts better
|
Numerator 35 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 4.31% |
2.29%
2 pts worse
|
Numerator 5 · Denominator 116 · Adjusted rate 3% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 4.96% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 0.57% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 176 |
| Staff flu vaccination coverage | 30.06% |
42%
11.9 pts worse
|
Numerator 101 · Denominator 336 |
| Discharge function score | 53.13% |
56.45%
3.3 pts worse
|
Numerator 34 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 65 · Denominator 65 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 24.56% |
25.2%
0.6 pts worse
|
Numerator 14 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · 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 | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.1% · Q3 2.0% · Q4 2.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 56.5% |
26.1%
30.4 pts worse
|
11.4%
45.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.0% · Q2 50.6% · Q3 56.0% · Q4 62.2% · 4Q avg 56.5% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.2%
About the same
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.9% · Q3 4.6% · Q4 9.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
25.4%
1.4 pts better
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 26.4% · Q3 21.8% · Q4 24.4% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.5% |
11.5%
6 pts better
|
16.7%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 8.3% · Q3 6.7% · Q4 2.7% · 4Q avg 5.5% · 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 | 7.6% |
7.7%
0.1 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 0.0% · Q3 14.3% · Q4 8.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
6.2%
0.5 pts worse
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.8% · Q3 12.5% · Q4 4.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.2%
0.9 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 2.3% · Q4 0.0% · 4Q avg 1.1% · 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 | 28.8% |
21.7%
7.1 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 30.7% · Q3 28.7% · Q4 29.4% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
3.7%
0.6 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.8% · Q3 6.2% · Q4 0.6% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
78.1%
21.6 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
12.5%
2.9 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 10.5% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 1.4% · Q4 1.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
75.6%
21.4 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.7% |
25.1%
3.6 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 31.4% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-27 · Fire 2023-04-27
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2020-02-13 · Fire 2020-02-13
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-21
F · Potential for more than minimal harm
2023-04-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-17
F · Potential for more than minimal harm
2020-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-20
F · Potential for more than minimal harm
2020-02-13
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 2020-03-20
E · Potential for more than minimal harm
2020-02-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-03-20
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-11-19
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 2025-11-21
D · Potential for more than minimal harm
2025-04-25
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 2025-03-19
J · Immediate jeopardy
2024-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-25
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 2024-09-10
D · Potential for more than minimal harm
2024-11-25
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 2024-12-17
D · Potential for more than minimal harm
2024-11-25
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-25
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-25
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 2024-12-17
D · Potential for more than minimal harm
2024-11-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-17
D · Potential for more than minimal harm
2023-07-18
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 2023-07-25
D · Potential for more than minimal harm
2023-04-27
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 2023-05-05
D · Potential for more than minimal harm
2023-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-05
Penalties and ownership
What sits behind the stars
$22,925
2025-11-19
Fine
Fine · fine $22,925
Fine
$17,820
2024-11-25
Fine
Fine · fine $17,820
Fine
Ownership
Carespring Health Care Holdings LP
5% Or Greater Direct Ownership Interest · Organization
Barry N Bortz 06042009 Tr
5% Or Greater Indirect Ownership Interest · Organization
Eppers, David
5% Or Greater Indirect Ownership Interest · Individual
Bortz Family Trust/Key Bank Trustee
5% Or Greater Indirect Ownership Interest · Organization
Carespring Health Care Management, LLC
Operational/Managerial Control · Organization
Carespring Leasing, LLC
Operational/Managerial Control · Organization
Chirumbolo, Christopher
Corporate Officer · Individual
Eppers, David
Corporate Officer · Individual
Mcgill, Emily
W-2 Managing Employee · Individual
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