Cycle 1
Health 2023-07-20 · Fire 2023-07-20
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cincinnati, OH
Marjorie P Lee Retirement Community
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3550 Shaw Avenue, Cincinnati, OH
(513) 871-2090
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Episcopal Retirement Homes, Inc.
Operator or chain grouping
Approved since
1990-07-28
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
0.90
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.73
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.70
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
5.35
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
6.27
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,349
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.37
Composite VBP score used to determine payment impact.
Payment multiplier
1.0125
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.02% · Performance 21.94% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.77
Baseline 4.57% · Performance 6.41% · Measure score 4.77 · Achievement 4.77 · Improvement 0
Total nurse turnover
8.18
Baseline 46.15% · Performance 30.25% · Measure score 8.18 · Achievement 8.18 · Improvement 6.96
Adjusted total nurse staffing
10
Baseline 5.84 hours · Performance 5.99 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 245 · Observed rate 8.16% · Lower 95% interval 7.63% |
| Discharge to community | 61.28% |
50.57%
10.7 pts better
|
Better than the National Rate · Eligible stays 234 · Observed rate 64.96% · Lower 95% interval 56.95% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.12% |
95.27%
1.9 pts better
|
Numerator 135 · Denominator 139 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 139 |
| Discharge self-care score | 43.64% |
53.69%
10 pts worse
|
Numerator 48 · Denominator 110 |
| Discharge mobility score | 53.64% |
50.94%
2.7 pts better
|
Numerator 59 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 0.72% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 139 · Adjusted rate 0.94% |
| Healthcare-associated infections requiring hospitalization | 6.41% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 3.73% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 2.37% |
8.2%
5.8 pts worse
|
Numerator 6 · Denominator 253 |
| Staff flu vaccination coverage | 43.46% |
42%
1.5 pts better
|
Numerator 123 · Denominator 283 |
| Discharge function score | 56.36% |
56.45%
0.1 pts worse
|
Numerator 62 · Denominator 110 |
| Transfer of health information to provider | 96.84% |
95.95%
0.9 pts better
|
Numerator 92 · Denominator 95 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 32.86% |
25.2%
7.7 pts better
|
Numerator 23 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.8
1.1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.5%
3.8 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.6% |
3.3%
6.3 pts worse
|
3.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.9% · Q3 11.7% · Q4 8.6% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.1% |
26.1%
5 pts better
|
11.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 12.5% · Q3 22.0% · Q4 27.3% · 4Q avg 21.1% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.2%
1 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.7% · Q3 6.7% · Q4 4.3% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
25.4%
20 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.4% · Q3 6.2% · Q4 2.2% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
11.5%
10.2 pts worse
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 25.6% · Q3 20.5% · Q4 17.6% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.3% |
7.7%
5.6 pts worse
|
16.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.4% · Q3 11.5% · Q4 24.0% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
6.2%
3.2 pts worse
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 15.2% · Q3 8.3% · Q4 7.0% · 4Q avg 9.4% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.5%
0.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
21.7%
5.2 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 26.3% · Q3 22.2% · Q4 24.2% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
3.7%
0.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.2% · Q3 5.5% · Q4 2.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
78.1%
13.6 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 93.4% · Q3 92.2% · Q4 90.9% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
12.5%
1.8 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 12.5% · Expected 9.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
75.6%
13.3 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
25.1%
1 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 20.8% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-28 · Fire 2019-12-28
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-10-11 · Fire 2018-10-11
7 health deficiencies
Top issue: Pharmacy Service (3 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
2023-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-07-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-07-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-07-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-07-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-07-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-07-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-13
E · Potential for more than minimal harm
2019-12-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-02-12
E · Potential for more than minimal harm
2019-12-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-02-12
E · Potential for more than minimal harm
2019-12-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-12
E · Potential for more than minimal harm
2019-12-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-02-12
F · Potential for more than minimal harm
2018-10-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-11-30
E · Potential for more than minimal harm
2018-10-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-11-30
E · Potential for more than minimal harm
2018-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-11-30
E · Potential for more than minimal harm
2018-10-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-11-30
Inspection history
Recent health citations
G · Actual harm
2025-04-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-22
F · Potential for more than minimal harm
2018-10-11
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 2018-11-30
D · Potential for more than minimal harm
2018-10-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-11
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-11
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 2018-11-30
D · Potential for more than minimal harm
2018-10-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-11-30
Penalties and ownership
What sits behind the stars
Ownership
Episcopal Retirement Homes, Inc.
5% Or Greater Direct 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
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
Corporate Officer · 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
Steward, Daniel
Operational/Managerial Control · Individual
Steward, Daniel
Corporate Officer · Individual
Williams, Anthony
Operational/Managerial Control · Individual
Woods, William
Corporate Director · Individual
Workman, David
Corporate Director · Individual
Zwilling, Elizabeth
Corporate Director · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Carecore At Margaret Hall
Cincinnati, OH
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Arc At Cincinnati
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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
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