Inspection visit
Inspection
24 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 24 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, review of Resident Council meeting minutes, review of the facility's policy, and
resident and staff interviews, the facility failed to respond to grievances identified at the Resident Council
meetings. This affected two (Residents #8 and #12) of three residents interviewed regarding Resident
Council meetings. The facility census was 41.
Residents Affected - Few
Findings include:
Record review for Resident #8 revealed an admission date of 10/14/21. Diagnoses included chronic kidney
disease stage three, anxiety disorder, and polyarthritis. Review of the Minimum Data Set (MDS)
assessment, dated 04/22/22, revealed Resident #8 had mild cognitive impairment.
Record review for Resident #12 revealed an admission date of 01/24/21. Diagnoses included Parkinson's
disease, bipolar disorder, and adult failure to thrive. Review of the quarterly MDS assessment, dated
05/01/22 revealed Resident #12 was cognitively intact.
Interviews during Resident Council meeting on 07/07/22 at 10:40 A.M. revealed Resident #8 stated the
facility staff does not follow up on concerns brought to the attention of the Resident Council. Resident #12
stated she has the same concern. Resident #12 stated she has brought issues and concerns to the
Resident Council meetings, and the facility never followed up on her issues and concerns. Resident #8
stated she feels the concerns were not addressed and not followed up on. Both residents provided
examples of bringing their concerns of agency staff and their lack of customer service and approach.
Resident #8 and #12 stated they have not received follow up regarding agency staff.
Review of the Resident Council meeting minutes, dated January 2022 through March 2022, revealed the
facility failed to have a Resident Council meeting for the months of March 2022 and April 2022 and no
issues were identified for February 2022. However, during the months of January 2022, May 2022, and
June 2022, the Resident Council met and brought forward concerns or grievances for the facility to address.
There was no indication the concerns or grievances were followed up by the facility.
Interview with the Activity Director (AD) #359 on 07/07/22 at 11:03 A.M. revealed she provides the resident
council notes with the grievances and concerns to the Administrator. AD #359 could not confirm if the
grievances were followed up on because they were given to the Administrator.
Interview on 07/07/22 at 2:32 P.M. with the Administrator confirmed the facility failed to have Resident
Council Meetings for the month of March 2022 and April 2022. The Administrator confirmed the facility did
not address or provide follow up regarding any of the concerns or grievances brought forth from Resident
Council for the months reviewed January 2022 through June 2022.
(continued on next page)
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
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
365798
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0565
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's policy titled Resident Council/Association, dated 09/09/21, revealed the facility
representative will be responsible for researching state regulatory guidelines to meet their specific
regulations for their community setting and population.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident#16's medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses
included cerebral infarction, dementia, major depressive disorder, vascular dementia, and anxiety disorder.
Residents Affected - Few
Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/07/22, revealed Resident #16 had
severely impaired cognition. Resident #16 required extensive assistance with bed mobility and transfers.
Resident #16 was totally dependent on staff for dressing, eating, toilet use, and personal hygiene.
Review of Resident #16's progress notes dated 02/23/22 revealed a hospice nurse reported to the nurse
bruising and swelling identified on Resident #16's left foot third digit. The note stated Resident #16 did not
voice any complaints of pain.
Review of the facility's Self-Reported Incidents (SRI) control number 218341 revealed there was an
allegation of injury of unknown origin reported to the State Survey Agency. Resident #16 had a bruise of
unknown origin identified on 02/23/22. The bruise was located on the third digit toe on Resident #16's left
foot. The facility could not provide an investigation related to this SRI.
Interview on 07/07/22 at 3:11 P.M. with the Director of Nursing (DON) confirmed the facility did not have an
investigation on SRI 218341. The DON confirmed the facility reported the bruise of unknown origin to the
State Survey Agency as a reportable abuse; however, did not complete an investigation of the cause. The
DON stated Resident #16 was known to be combative with care, so the nursing staff assumed this was the
cause of the injured toe.
Review of the facility's policy titled Abuse Investigation, dated 02/21/12, revealed the facility will identify and
investigate all suspicions of abuse. The facility will complete a thorough investigation following an allegation
of abuse. The investigation will consists of notifying the physician, family, interviewing staff, and interviewing
residents among other steps.
Based on staff interview, medical record review, review of the facility's Self-Reported Incidents and
investigations, and policy review, the facility failed to complete thorough investigations of allegations of
resident abuse. This affected two (Resident #16 and #97) of three residents reviewed for abuse. The facility
census was 41.
Findings include:
1. Review of the medical record for Resident #97 revealed an admission date of 02/21/22 with a discharge
date of 03/23/22. Diagnoses included multiple fractures of pelvis and chronic obstructive pulmonary
disease.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had
intact cognition. Resident #97 required one-person extensive assistance with transfers, dressing, toileting,
and bathing.
Review of Resident #97's medical record revealed no documentation of an incident occurring on 02/25/22.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the self-reported incident (SRI) control number 218359 revealed Resident #97 reported an
allegation of neglect on 02/25/22. Resident #97 reported Licensed Practical Nurse (LPN) #343 came into
her room to provide care. At that time, LPN #343 asked Resident #97 to turn down her television and was
unable to transfer Resident #97. The Director of Nursing (DON) interviewed Resident #97. Resident #97
reported LPN #343 told her loudly to turn down the television, and night shift was unable to transfer her at
that time. The DON spoke to LPN #343. LPN #343 stated Resident #97's family requested staff to
encourage her to turn off her television at night for rest. LPN #343 explained to Resident #97 the
importance of sleep. LPN #343 reported Resident #97 was hard of hearing and raised her voice to speak
over oxygen concentrator and the television. LPN #343 revealed Resident #97 requested to get in her
recliner at 4:00 A.M., and LPN #343 explained she was doing medication pass and would not be able to
assist her at that time. Resident #97 requested to get up to use the restroom. LPN #343 explained Resident
#97 was incontinent and felt she was being manipulative to get out of bed. LPN #343 educated Resident
#97, and Resident #97 agreed to wait until day shift to get out of bed. Social services will meet with
Resident #97 to determine when she would like to get out of bed in the mornings and update her care plan.
Staff will be educated on how to accommodate resident's needs.
Review of the facility's investigation revealed it did not include staff and resident statements. The
investigation did not include any skin assessments of Resident #97 to assess if Resident #97 had any skin
impairments related to lack of assistance with toileting when Resident #97 requested to utilize the
restroom. The investigation did not include any assessments or interviews of nearby residents.
Interview on 07/07/22 at 2:56 P.M. with the DON verified the facility's information regarding SRI 218359 was
very limited and reported previous Administrator completed this abuse investigation. The DON reported the
facility interviewed residents on the same hall where the incident occurred but unable to obtain the
documentation. The DON verified there was no skin assessment completed for Resident #97 after the
allegation of neglect.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interview, review of the facility's policy, and record review, the facility failed to provide written
notification of the resident's transfer to the hospital to the residents and/or their representatives. This
affected two (Residents #27 and #32) of four residents reviewed for transfers. The facility census was 41.
Findings include:
1. Review of the medical record for Resident #32 revealed an admission date of 06/01/22 with surgical
aftercare following surgery, pain in right hip and pain in right leg. Review of the Minimum Data Set (MDS)
assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of the physician's order
dated 05/25/22 revealed Resident #32 was to go to the hospital.
Review of the progress note dated 05/25/22 at 7:26 P.M. revealed Resident #32 had uncontrollable pain in
her right hip and right leg. Pharmacological and non-pharmacological interventions were attempted without
relief. The physician ordered Resident #32 be sent to the emergency room for further evaluation. There was
no evidence Resident #32 received a written notice of transfer.
Interview on 07/07/22 at 9:02 A.M. with the Director of Nursing (DON) verified the facility was not providing
a written reason for transfer to the resident and/or resident's representative. The DON stated they had a
change in personnel and the written reason for transfer was not being completed.
2. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included anxiety disorder, heart failure, paraplegia, and obstructive sleep apnea. Review of the
quarterly Minimum Data Set (MDS) assessment, dated 06/21/22, revealed Resident #27 was cognitively
intact.
Review of the progress notes revealed Resident #27 was discharged to the hospital on [DATE]. Resident
#27 returned from the hospital on [DATE]. There was no evidence the facility provided written notification of
transfer to the hospital to Resident #27.
Interview on 07/07/22 at 12:55 P.M. with the Director of Nursing (DON) verified the facility did provide
written notification of the resident's transfer to the hospital to Resident #27.
Review of the facility's policy titled Transfer, Discharge Notice, dated 03/07/18, revealed all
transfer/discharge notices must be sent to the resident, resident representative(s), the Long-Term Care
Ombudsman program, and any state specific agency, as required.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interview, review of facility's policy, and record review, the facility failed to provide bed hold notices to
the residents and their representatives when the residents transferred to the hospital. This affected two
(Residents #27 and #32) of four residents reviewed for bed hold notices. The facility census was 41.
Findings included:
1. Review of the medical record for Resident #32 revealed an admission date of 06/01/22 with surgical
aftercare following surgery, pain in right hip and pain in right leg. Review of the Minimum Data Set (MDS)
assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of the physician's order
dated 05/25/22 revealed Resident #32 was to go to the hospital.
Review of the progress note dated 05/25/22 at 7:26 P.M. revealed Resident #32 had uncontrollable pain in
her right hip and right leg. Pharmacological and non-pharmacological interventions were attempted without
relief. The physician ordered Resident #32 be sent to the emergency room for further evaluation. There was
no evidence Resident #32 received a bed hold notice when sent to the hospital
Interview on 07/07/22 at 9:02 A.M. with the Director of Nursing (DON) verified the facility did not provide
Resident #32 and/or resident's representative of a bed hold notice when Resident #32 went to the hospital
on [DATE]. The DON stated they had a change in personnel and the bed hold notices were not being
completed.
2. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included anxiety disorder, heart failure, paraplegia, and obstructive sleep apnea. Review of the
quarterly Minimum Data Set (MDS) assessment, dated 06/21/22, revealed Resident #27 was cognitively
intact.
Review of the progress notes revealed Resident #27 was discharged to the hospital on [DATE]. Resident
#27 returned from the hospital on [DATE]. There was no evidence the facility provided a bed hold notice to
Resident #27.
Interview on 07/07/22 at 12:55 P.M. with the Director of Nursing (DON) verified the facility did not provide
Resident #27 and/or resident's representative a bed hold notice when Resident #27 went to the hospital on
[DATE]. The DON stated they had a change in personnel and the bed hold notices were not being
completed.
Review of the facility's policy titled Transfer, Discharge Notice, dated 03/07/18, revealed the facility will
provide notice of their Bed-Hold policy to the resident and representative at the time of admission and again
with emergency transfer from the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of the facility's policy, and staff interviews, the facility failed to hold quarterly
care conferences with residents. This affected one (Residents #10) of 16 residents reviewed for care
conferences. The facility census was 41.
Findings include:
Review of the medical record for Resident #10 revealed an admission date of 09/08/21. Diagnoses included
congestive heart failure (CHF), Parkinson's disease, type two diabetes mellitus, atrial fibrillation, liver
disease, and chronic kidney disease, stage III. Review of the Minimum Data Set (MDS) assessment dated
[DATE] revealed Resident #10 was cognitively intact.
Review of the care conferences from 06/21/21 to 07/07/22 revealed Resident #10 had care conferences on
06/21/21, 09/20/21, and 12/08/21. There was no additional care conference documentation available after
12/08/21.
Interview on 07/07/22 at 9:41 A.M. with Social Services Director (SSD) #300 verified all care conference
documentation was in the electronic medical records. SSD #300 verified Resident #10's last care
conference was 12/08/21.
Review of the facility's policy titled, Care Plan Process-Skilled, dated 07/07/22, revealed to ensure the
timeliness of each resident's person-centered, baseline and comprehensive care plan, and to ensure that
these care plans are reviewed and revised by an interdisciplinary team composed of individuals who have
knowledge of the resident and his/her needs, and that each resident and resident representative, if
applicable, is involved in developing the care plan and making decisions about his or her care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
Based on staff interview, review of the facility's policy, and record review, the facility failed to ensure
residents were weighed as ordered, residents were re-weighed as needed and timely documentation of
addressing the resident's weight changes. This affected one (Resident #10) of five residents reviewed for
nutrition. The facility identified four residents with unplanned significant weight gain or loss. The facility
census was 41.
Residents Affected - Few
Findings include:
Review of the medical records for Resident #10 revealed an admission date of 09/08/21. Diagnoses
included congestive heart failure, Parkinson's disease, type two diabetes mellitus type two, atrial fibrillation,
liver disease, and chronic kidney disease, stage III.
Review of the Minimum Data Set (MDS) assessment, dated 04/22/22, revealed Resident #10 was
cognitively intact and required supervision and setup help only for eating.
Review of the physician's orders dated 10/29/21 revealed Resident #10 had an order on for monthly
weights. Review of Resident #10's weights revealed the following weights: 166.6 pounds (lbs.) on 01/07/22;
174.0 lbs on 01/08/22, 158.0 lbs. on 04/26/22; and 116.0 lbs on 05/01/22. On 05/01/22, it was a 26.5%
significant weight loss. There was no re-weight listed for May 2022 and no June 2022 weight listed in the
medical record.
Further review of the medical record revealed there was no documentation addressing a re-weight was
needed for May 2022 and no documentation related to why there was no weight for June 2022.
Interview on 07/06/22 at 3:07 P.M. with Registered Dietitian (RD) #361 stated on 05/01/22 at 116.0 lbs.
weight was in error. RD #361 stated she would ask for for re-weights by providing the Director of Nursing
(DON) with a report. RD #361 verified that there was no dietary note from her related to the weight on
05/01/22 and verified that there were no monthly weight for June 2022. RD #361 stated the facility's policy
was for residents to be weighed monthly by the 10th of the month.
Interview on 07/06/22 at 4:48 P.M. with the Director of Nursing (DON) stated the nurses on the floor should
be checking and getting residents re-weighed at that time of unusual weights, then notify the physician if
there was a significant change. Aides would not be aware of previous weights, only nurses. The DON
verified there was no documentation to support nursing contacted the physician.
Review of the facility's policy titled Weights Policy, dated 03/03/21, revealed all residents will be weighed
monthly by the 10th of the month with weights recorded on the Vital Sign Flow Sheet or the electronic
health record (EHR) and in the Weight Log Form. If a discrepancy in weight is noted, the resident will be
re-weighed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation of tray line and a test tray, resident, family, and staff interview, review of the resident
council meeting minutes, review of the facility's policy, and record review, the facility failed to ensure food
was served at an appetizing temperature and acceptable palatability. This had the potential to affect 40
residents who received food from the kitchen. The facility identified one resident (#37) who did not receive
food from the kitchen. The facility census was 41.
Residents Affected - Many
Findings include;
Interview on 07/05/22 at 10:28 A.M. with Resident #141 stated the facility's food was often served cold and
this issue was ongoing.
Interview on 07/05/22 at 11:15 A.M. with Resident #142 stated the food was served cold. Resident #142
stated this was really the only concern or complaint regarding the facility's food.
Interview with Resident #4's spouse on 07/05/22 at 12:29 P.M. stated there were times the hot food was
served cold.
Observation on 07/06/22 at 11:34 A.M. revealed Dietary [NAME] (DC) #500 placed a food thermometer in a
pan of mixed vegetables without sanitizing the thermometer and obtaining a temperature of 199 degree
Fahrenheit (F). DC #500 wiped the food thermometer with a dry dish towel and placed it in a large pan of
black bean salad and obtain a temperature of 196 degrees F. DC #500 was observed wiping the food
thermometer with a dry dishtowel and placing in the meat of a quesadilla and obtaining a holding
temperature of 122.5 degrees F. DM #362 was observed to provide DC #500 a alcohol wipe and
encouraged him to clean the food thermometer with the alcohol wipes. DM #362 explain to DC #500 the
holding temperature for the beef quesadilla was too low and to put in the oven to bring to a temperature of
165 degrees F.
Observation of the tray line on 07/06/22 at 12:12 A.M. revealed the tray line was located in the temporary
kitchen area due to remodeling. DM #362 stated the facility does not have enough lids to cover the food
dishes to ensure the foods stays hot. Observed the tray line run out of lids to cover the food and placed the
food in a four-compartment styrofoam container. DM #362 stated the reason they do not have enough lids
was because her supplier has them on back order. DM #362 stated she has checked with three suppliers,
however, has not asked the current supplier she was using.
Observation of meal trays delivered to the floor on 07/06/22 at 12:38 P.M. revealed the last tray was
delivered to a resident at 12:38 P.M A test tray was completed at this time and revealed the lunch was
served in a styrofoam container and the black beans were served at room temperature. The quesadilla was
beef in a flour tortilla wrap with nothing else on it. There was no cheese or garnish like sour cream and/or
salsa. The tortilla was cold and chewy.
An interview on 07/06/22 at 3:24 P.M. with the Registered Dietitian (RD) #361 revealed the RD was unable
to determine why the facility would serve a plain quesadilla that consisted of beef wrapped in a shell without
cheese or garnish. The RD stated the quesadillia should have contained cheese. The RD stated she was
unaware the facility did not have enough lids to ensure the foods served remained hot on the unit.
Review of the resident's diets revealed Resident #37's diet was nothing by mouth.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of the facility's Resident Council Meeting Notes dated 05/17/22 revealed Resident #12 had an issue
of cold food on her tray. The Resident Council Meeting Notes dated 06/21/22 revealed Resident #12 had
the same issue that her food on her tray was often cold and it was an ongoing issue.
Review of the facility's policy titled Food Preparation-Food Temperatures Policy, dated 09/05/19, revealed
foods should be served at proper temperature to insure food safety and palatability.
Event ID:
Facility ID:
365798
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, record review, review of the facility's policy, and staff interview, the facility failed to
maintain a clean and sanitary kitchen area. This had the potential to affect 40 residents who received food
from the kitchen. The facility identified one resident (#37) who did not receive food from the kitchen. The
facility census was 41.
Findings include:
Observation and interview during the initial tour of the facility's kitchen on 07/05/22 at 8:12 A.M. revealed
Dietary Manager (DM) #362 was standing in the kitchen area without a hair net covering her hair. The
dining room manger (DRM) #322 was standing at the counter with no hair net covering her hair. DM #362
confirmed the findings. DM #362 provided a tour of the kitchen and confirmed an employee lunch was
located inside the facility's refrigerator. A pound cake was observed on a shelf in the refrigerator with no
label or date. DM #362 confirmed a large bag of open frozen cookies with no label or date. DM #362
opened the free standing ice cream cooler and revealed four three gallon tubs of ice cream with no lids. DM
#362 confirmed the ice cream should be covered and labeled with a date.
Observation on 07/06/22 at 11:34 A.M. revealed Dietary [NAME] (DC) #500 placed a food thermometer in a
pan of mixed vegetables without sanitizing the thermometer. DC #500 then wiped the food thermometer
with a dry dish towel and placed the thermometer in a large pan of black bean salad. DC #500 was
observed wiping the food thermometer with a dry dishtowel and placing in the meat of a quesadilla. DM
#362 then gave DC #500 a alcohol wipe and encouraged him to clean the food thermometer utilizing the
alcohol wipe.
Interview on 07/06/22 at 11:34 A.M. with DC #500 confirmed he did not sanitize the food thermometer while
obtaining the food temperatures.
Review of the resident's diets revealed Resident #37's diet was nothing by mouth.
Review of the facility's policy titled Food Preparation Policy, dated 08/20/18, revealed food items should be
stored following good sanitary practices and local codes and manufactories specifications.
Review of the facility's policy titled General Cleaning and Sanitizing, dated 03/18/21, revealed food contact
surfaces must be cleaned and sanitized after every use.
Review of the facility's policy titled Personal Hygiene Policy-Personal Hygiene, dated 08/20/18, revealed for
staff to wear a clean hat or other hair restraint in all kitchen production/food service areas. Hair must be
appropriately restrained per state regulations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyard at Seasons
7100 Dearwester Drive
Cincinnati, OH 45236
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Potential for
minimal harm
Based on staff interview, review of the facility's policy and risk assessment, and review of the employee
files, the facility failed to ensure the facility newly hired staff received the second step of the tuberculin skin
test (TST). This had the potential to affect all 41 residents residing in the facility. The facility census was 41.
Residents Affected - Many
Findings include:
Review of the employee file for State Tested Nursing Assistant (STNA) #326, revealed a hire date of
06/07/22. Further review of the employee file revealed a form titled Initial TB testing for Residents and
Health Care Workers, dated 01/28/21, revealed the first TB step was completed on 05/27/22 and results
were read on 05/30/22. However, the second step was blank and not completed.
Review of the employee file for STNA #316 revealed a hire date of 05/12/22. Review of the form titled Initial
TB testing for Residents and Health Care Workers, dated 01/28/22, revealed the first TB step testing was
completed on 04/27/22 and results read on 04/29/22. However, the second step was blank and not
completed.
Review of the employee file for STNA #350 revealed a hire date of 05/31/22. Review of the form titled Initial
TB testing for Residents and Health Care Workers, dated 01/28/22, revealed the first TB step testing was
completed on 05/06/22 and results were read on 05/09/22. However, the second step was blank and not
completed.
Interview on 07/07/22 at 2:32 P.M. with the Director of Nursing (DON) revealed the facility failed to complete
the second TB testing for new hires STNA #326, #316 and #350.
Review of the facility's TB risk assessment titled Tuberculosis (TB) risk assessment worksheet, dated 2022,
revealed the facility will assess employees for TB upon hire and PRN (as needed).
Review of the facility's policy titled Community-Employee Tuberculosis Testing Policy, dated 02/10/22,
revealed it is the standard for the company that all employees receive a two-step intra-cutaneous (Mantoux)
test.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365798
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
24 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Epotential for harm
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.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the July 12, 2022 survey of COURTYARD AT SEASONS?
This was a inspection survey of COURTYARD AT SEASONS on July 12, 2022. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COURTYARD AT SEASONS on July 12, 2022?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.