Cycle 1
Health 2025-07-17 · Fire 2025-07-17
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cincinnati, OH
Deupree Cottages
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3999 Erie Avenue, Cincinnati, OH
(513) 272-5555
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
24
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Episcopal Retirement Homes, Inc.
Operator or chain grouping
Approved since
2010-05-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 5 overall / 4 health / 5 staffing / 4 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
1.16
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.69
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.43
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.86
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.56
CMS adjusted RN staffing hours
Adjusted total hours
7.33
CMS adjusted total nurse staffing hours
Case-mix index
1.01
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 6 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.11% |
8.2%
4.9 pts better
|
Numerator 8 · Denominator 61 |
| Staff flu vaccination coverage | 67.77% |
42%
25.8 pts better
|
Numerator 82 · Denominator 121 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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% · 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 | 7.6% |
3.3%
4.3 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.5% · Q4 5.0% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
26.1%
22.1 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 13.3% |
6.2%
7.1 pts worse
|
5.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
25.4%
17.2 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
11.5%
15.8 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.9% |
7.7%
2.2 pts worse
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
6.2%
5.3 pts worse
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% · 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% · 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% · 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 | 13.9% |
21.7%
7.8 pts better
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
78.1%
16.6 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 94.7% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-09 · Fire 2022-11-09
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-08-21 · Fire 2019-08-21
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-17
K222 · Egress Deficiencies
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 2025-09-05
F · Potential for more than minimal harm
2025-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-05
E · Potential for more than minimal harm
2025-07-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-05
F · Potential for more than minimal harm
2022-11-09
K222 · Egress Deficiencies
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 2023-01-05
F · Potential for more than minimal harm
2022-11-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-05
F · Potential for more than minimal harm
2022-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-11-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-05
F · Potential for more than minimal harm
2019-08-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-10-10
F · Potential for more than minimal harm
2019-08-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-10-10
F · Potential for more than minimal harm
2019-08-21
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
F · Potential for more than minimal harm
2022-11-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-05
F · Potential for more than minimal harm
2019-08-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-21
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2019-10-10
C · Minimal harm
2019-08-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-10-10
Penalties and ownership
What sits behind the stars
Ownership
Episcopal Retirement Homes, Inc.
5% Or Greater Direct Ownership Interest · Organization
Episcopal Retirement Services
5% Or Greater Indirect Ownership Interest · Organization
Anim, Dora
Corporate Director · Individual
Cooper, W.
Corporate Director · Individual
Edwards, Beverly
Operational/Managerial Control · Individual
Edwards, Beverly
Corporate Officer · Individual
Elin, Reverend Darren
Corporate Director · Individual
Episcopal Retirement Homes, Inc.
Operational/Managerial Control · Organization
Episcopal Retirement Services
Operational/Managerial Control · Organization
Fraser, Bonita
Operational/Managerial Control · Individual
Fritschner, John
Corporate Director · Individual
Hagopian, Joann
Corporate Director · Individual
Hartman, Alan
Corporate Director · Individual
Hopkins, Gregory
Corporate Director · Individual
Kearney, Eric
Corporate Director · Individual
Koepke, John
Corporate Director · Individual
Lamb, Laura
Operational/Managerial Control · Individual
Lamb, Laura
Corporate Officer · Individual
Mccaughey, Wendy
Operational/Managerial Control · Individual
Mcknight, Gerron
Corporate Director · Individual
Payne, Jennifer
Corporate Director · Individual
Pope, Apryl
Corporate Director · Individual
Regan, Thomas
Corporate Director · Individual
Retford, David
Corporate Director · Individual
Schlaudecker, Jeffrey
Operational/Managerial Control · Individual
Smitherman, Albert
Corporate Director · Individual
Stambaugh, Emerson
Operational/Managerial Control · Individual
Steward, Daniel
Operational/Managerial Control · Individual
Steward, Daniel
Corporate Officer · Individual
Workman, David
Corporate Director · Individual
Zwilling, Elizabeth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Arc At Cincinnati
Cincinnati, OH
1-star overall rating with 1-star inspections with $110,557 in total fines with 40 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
#2
Marjorie P Lee Retirement Community
Cincinnati, OH
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Indianspring Of Oakley
Cincinnati, OH
3-star overall rating with 3-star inspections with $26,685 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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