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
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
1.06
Licensed practical nurse staffing
Aide hours / resident day
3.73
Nurse aide staffing
Weekend hours
5.35
Weekend nurse staffing
RN turnover
13%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
#1
Beechwood Home For Incurables
Cincinnati, OH
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
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
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