West Chester Hospital
An acute care hospital in West Chester, Ohio 45069
7700 University Drive, West Chester, Ohio 45069. (513) 298-7701.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 3 deficiencies cited in the last three years (needs attention)
- 162 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Mar 5, 2026: a complaint inspection.
3 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
3 deficiencies in 2 months of the last 36. Last cited Aug 2024. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Aug 7, 2024: complaint inspection2 deficiencies
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Nursing Services
“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 28999 Based on observation, record review, interview, policy review, and review of manufacturer’s instructions, the facility failed to ensure the appropriate size condom catheter was used to prevent skin breakdown. See A392.”
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Staffing And Delivery Of Care
The inspectors’ words, 787 words
“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 28999 Based on observation, record review, interview, policy review, and review of manufacturer’s instructions, the facility failed to ensure the appropriate size condom catheter was used to prevent skin breakdown. This affected two (Patients #1 and #3). The hospital census was 141. Findings include: 1. Review of the medical record of Patient #1 revealed the patient presented to the emergency department (ED) on 06/15/24 at 4:28 PM with worsening shortness of breath over last couple of days. The patient was admitted to the Stepdown Unit at 9:22 PM. A nursing note at 10:16 PM stated the patient reported wearing a brief for incontinence at home. Review of physician orders revealed an order to apply external urinary catheter The lines/drains/airways flow sheet revealed a size small condom catheter was applied by a staff Registered Nurse (Staff J) at 11:00 PM. The patient’s skin around the genitalia was intact. A nursing assessment on 06/16/24 at 8:00 PM revealed the patient’s penis was swollen. The condom catheter was removed at 10:00 PM. The reason for removal was compromised skin integrity. A wound nurse consult was ordered. A note composed by a wound nurse on 06/17/24 at 9:25 AM stated there was a new mucous membrane pressure injury over the lower and right lateral penis beneath the foreskin. 2. Review of the medical record of Patient #3 revealed the patient arrived to the ED from home on 06/20/24 at 11:09 AM with altered mental status and lethargy. The patient was admitted to the Intensive Care Unit at 5:33 PM. Review of physician orders revealed an order to insert a Foley catheter on 06/20/24 at 3:38 PM. The patient was anuric in nursing assessments. The Foley catheter was inserted as ordered on 06/20/24 at 11:48 AM. A physician ordered for the Foley catheter to be discontinued on 06/21/24 and it was removed at 4:30 PM. A condom catheter was placed on 06/21/24 at 5:00 PM. The condom catheter was removed on 06/23/24 at 7:00 AM. A note on 06/24/24 at 8:45 AM composed by a wound care registered nurse stated a deep tissue injury on the penis due to the condom catheter was assessed. During an observation on 08/06/24 at 4:00 PM, the supply room of the Stepdown/ICU Unit contained three storage bins containing condom catheters in sizes small, medium and large. During an interview on 08/06/24 at 4:00 PM, Registered Nurse Staff I stated she approximates the size when determining what size condom catheter to use on a patient. She said there are times when she starts out with a larger size and if there is no urine leaking around it, it is fine. If there is leaking noted, she goes down a size. Staff G, present during the tour, explained that all condom catheters are delivered to main campus from the manufacturer. Staff at main campus removes individual catheters and deliver them to this location. There is a measuring wheel that comes with the condom catheters, however, the wheel is not included with the delivery of condom catheters. There were no wheels to ascertain appropriate condom catheter sizes in the facility. During an interview on 08/06/24 at 6:05 PM, Staff G confirmed that staff members did not follow either the facility policy or manufacturer’s instructions as there is no measuring tool to ensure correct sizing for condom catheters. This resulted in hospital-acquired pressure injuries in two patients. The facility policy titled “Indwelling and External Urinary Catheter Care, Maintenance & Removal Protocol”, effective 12/17/19, stated an external urinary catheter is a drainage device that resides outside the body but allows for safe drainage of urine to a collection system. Staff members are instructed they must verbalize that the clinical indications for placement are urinary incontinence and limited mobility. Staff members are to use the sizing guide to determine the appropriate size. Condom catheters are to be changed at least every 24 hours. According to the manufacturer instructions for the Bard condom catheter, the catheters are available in different sizes. Healthcare workers are instructed to measure the circumference of the penis at the base of the shaft. This is the place that the girth is the largest. It is important to ensure that the condom fit is secure but not too tight to avoid penile ulceration, scarring or penile tissue loss.”
Dec 6, 2023: complaint inspection1 deficiency
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Staffing And Delivery Of Care
The inspectors’ words, 411 words
“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 42492 Based on record review, interview, and policy review, the facility failed to provide pain management in a timely manner. This affected one (Patient #7) of ten patients reviewed. Findings include: Review of the medical record revealed Patient #7 was admitted to the hospital on 05/09/23 for a scheduled laminectomy surgery and was discharged to home on 05/12/23. Review of the medical record revealed Patient #7 was transferred from the Post-Anesthesia Care Unit (PACU) to Medical-Surgical (MedSurg) 4 unit on 05/09/23 at 4:37 P.M. At 4:41 P.M. the patient complained to the nurse she was experiencing pain to her back, rating it a ten on a one to ten pain scale. Review of physician orders revealed on 05/09/23 at 4:56 P.M., the physician placed an order for Dilaudid 1 milligram (mg) intravenously (IV) every two hours as needed for pain with a pain scale rating between seven and ten. Review of the pain assessment completed on 05/09/23 at 5:20 P.M. revealed Patient #7 complained of continuous sharp back pain, rating it an eight on a one to ten scale. A cold pack was applied. Review of the medical record revealed the pharmacy verified the order for Dilaudid 1 mg IV every two hours as needed for severe pain on 05/09/23 at 5:26 P.M. Review of the Medication Administration Record revealed Patient #7 received the first dose of Dilaudid 1 mg IV on 05/09/23 at 6:00 P.M. During an interview on 12/06/2032 at 10:13 A.M. RN Clinical Informatics Specialist P verified Patient #7 did not receive post-op pain medication on 05/09/23 until 6:00 P.M. after having complained of pain at 4:41 P.M. Review of the policy titled “Pain Management”, dated 12/30/15, revealed patients had the right to appropriate assessment and management of pain consistent with the total treatment plan. The nurse completed a pain assessment and attempted non-pharmacological pain interventions before administering pain medications and completed a pain re-assessment within 45 minutes for IV administrations and within 90 minutes of oral administration to determine the effectiveness and safety of pain interventions.”
All 8 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Mar 5, 2026 | Complaint inspection | No deficiencies cited |
| Feb 17, 2026 | Complaint inspection | No deficiencies cited |
| Oct 7, 2025 | Complaint inspection | No deficiencies cited |
| May 12, 2025 | Complaint inspection | No deficiencies cited |
| Jan 14, 2025 | Complaint inspection | No deficiencies cited |
| Aug 7, 2024 | Complaint inspection | 2 deficiencies cited |
| Jul 9, 2024 | Complaint inspection | No deficiencies cited |
| Dec 6, 2023 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 6; safety of care, 1 better and 0 worse of 7; readmission, 0 better and 3 worse of 10.
- Patients rate it 3 of 5 in CMS’s patient survey (1,330 surveys completed, Oct 1, 2024 to Sep 30, 2025): 70% rated it 9 or 10 out of 10, and 70% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.1%, heart failure 10.3%, pneumonia 16.2%, COPD 9.8%, stroke 11.1%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 15.5%, heart failure 25.6%, pneumonia 18.7%, COPD 18.8%, hip or knee replacement 6%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 219 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
- 62% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 1 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since May 14, 2009.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 3 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 94% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Uc Health LLC owns 100% directly since Feb 20, 2009.
- Uc Health LLC runs it.
- 4 owners or officers are people: Craig Cain (managing employee (on the payroll)); Brian Veneman (managing employee (on the payroll)); Sarah Kohlhause (managing employee (on the payroll)); Charmaine S Rochester (corporate officer).
- CMS’s Provider of Services file records 1 change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Uc Health LLC | Owns 5% or more directly | 100% | Feb 20, 2009 |
| Uc Health LLC | Runs it (operational or managerial control) | Feb 20, 2009 |
How does it compare nearby?
- Of the 5 hospitals CMS lists in Butler County, 4 have an overall star rating from CMS: 4 rated 3 of 5.
- CMS rates this one 3 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Beckett Springs | Not given |
| Mccullough-Hyde Memorial Hospital | 3 |
| Mercy Health - Fairfield Hospital | 3 |
| Fort Hamilton Hughes Memorial Hospital | 3 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.