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Complaint Investigation

Westover Retirement Community

November 25, 2025 · Hamilton, OH · 855 Stahlheber Road
Citations 3
CMS Rating 5/5
Beds 53
Provider ID 366232
Healthcare Facility
Westover Retirement Community
Hamilton, OH  ·  View full profile →
Inspection Summary

WESTOVER RETIREMENT COMMUNITY in HAMILTON, OH — inspection on November 25, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0641
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments.

This affected one resident (#43) of four resident assessments reviewed.

The facility census was 51.

Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety.

Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no oral or dental issues.

Observation on 11/19/25 at 1:58 P.M. of Resident #43 revealed the resident to be without natural upper teeth.Interview with Resident #43 at the time of the observation revealed the resident had lost several teeth since her admission to the facility. Resident #43 verbalized wishes to see a dentist however she has not been offered assistance in obtaining a dental appointment since her admission.

Interview on 11/20/25 at 10:38 A.M. with Minimum Data Set Registered Nurse (MDS RN) #70 revealed she was not certain if Resident #43 had upper natural teeth.

Interview on 11/25/25 at 2:50 P.M. with Licensed Practical Nurse (LPN) #71 confirmed Resident #43 was without upper natural teeth.

Interview on 11/25/25 at 3:31 P.M. with the Director of Nursing confirmed Resident #43's MDS assessment did not accurately reflect the resident's oral or dental status.

This deficiency represents non-compliance investigated under Master Complaint Number 2673309.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westover Retirement Community

855 Stahlheber Road Hamilton, OH 45013

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review and staff interview, the facility failed to follow a physician order for referral services.

This affected one Resident (#43) of four residents reviewed for physician orders for referral services.

The facility census was 51.

Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety.

Review of the provider progress note dated 07/22/25 revealed Resident #43 was seen by Nurse Practitioner (NP) #105 and the resident was referred to neurology related to neuropathy.

Review of the nurse's progress note dated 07/22/25 and timed 5:52 A.M. revealed a nurse's note stating Resident #43 was referred to neurology by NP #105 related to neuropathy.

Resident with left foot and leg heaviness, numbness and having a hard time lifting leg and foot.

Resident made aware of the referral.

Review of a provider's progress note dated 07/28/25 and signed at 2:58 P.M. by NP #105 revealed Resident #43 had previously been referred to neurology for left leg and foot heaviness and numbness.

Further review of the medical record for Resident #43 revealed no documentation of Resident #43 being seen by neurology.Interview on 11/25/25 at 11:06 A.M. with the Director of Nursing revealed she was unsure if Resident #43 was seen by a neurologist following the referral written by from NP #105 on 07/22/25.Interview on 11/25/25 at 1:58 P.M. with NP #105 revealed she had referred Resident #43 to neurology in July 2025 related to the resident's polyneuropathy. NP #105 was unable to verify if Resident #43 had been seen by a neurologist.

This deficiency represents non-compliance investigated under Master Complaint Number 2673309 and Complaint Number 2671315.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westover Retirement Community

855 Stahlheber Road Hamilton, OH 45013

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, medical record review, staff interview, and resident interview, the facility failed to ensure timely dental services.

This affected one resident (#43) of four residents reviewed.

The facility census was 51.

Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety.

Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no issues with oral or dental status.

Additional review of the medical record for Resident #43 revealed no documentation regarding a dental care plan or attempts to schedule a dental appointment.

Observation on 11/19/25 at 1:58 P.M. of Resident #43 revealed the resident to be without natural upper teeth.

Interview with Resident #43 at the time of the observation revealed the resident had lost several teeth since her admission to the facility. Resident #43 verbalized wishes to see a dentist however she has not been offered assistance in obtaining a dental appointment since her admission.

Interview on 11/25/25 at 2:50 P.M. with Licensed Practical Nurse (LPN) #71 confirmed Resident #43 had no natural upper teeth. LPN #71 further confirmed Resident #43 had lost teeth during her admission and that no dental appointments had been arranged.

This deficiency represents non-compliance investigated under Master Complaint Number 2673309 and Complaint Number 2671315.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HAMILTON, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTOVER RETIREMENT COMMUNITY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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