Cycle 1
Health 2024-11-13 · Fire 2024-11-13
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cincinnati, OH
Mount Notre Dame Health Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
699 East Columbia Avenue, Cincinnati, OH
(513) 821-7448
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
40
Certified beds
Average residents
35
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-08-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.93
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.43
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.79
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.36
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
5.20
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.43
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
0.87
CMS adjusted RN staffing hours
Adjusted total hours
5.43
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
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 21 · 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 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · 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 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 25.45% |
8.2%
17.2 pts better
|
Numerator 42 · Denominator 165 |
| Staff flu vaccination coverage | 28.82% |
42%
13.2 pts worse
|
Numerator 49 · Denominator 170 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · 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 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 0.8 · Expected 1.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.8
1.3 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.0 · Expected 1.1 · 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 | 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 | 3.4% |
3.3%
0.1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.4% · Q3 2.6% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.9% |
26.1%
16.2 pts better
|
11.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.9% · Q3 5.7% · Q4 8.8% · 4Q avg 9.9% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
6.2%
0.3 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.9% · Q3 8.3% · Q4 6.1% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.3% |
25.4%
14.1 pts better
|
19.6%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 11.1% · Q3 11.1% · Q4 15.2% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
11.5%
3.5 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 3.0% · Q3 10.7% · Q4 6.7% · 4Q avg 8.0% · 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 6.1% · Q2 9.3% · Q3 16.8% · Q4 22.6% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
6.2%
6.7 pts worse
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 8.6% · Q3 13.9% · Q4 15.6% · 4Q avg 12.9% · 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 | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 18.3% |
21.7%
3.4 pts better
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 26.9% · Q3 19.2% · Q4 12.6% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
3.7%
3 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-09-05 · Fire 2019-09-05
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-13
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-02
F · Potential for more than minimal harm
2022-10-13
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 2022-12-02
F · Potential for more than minimal harm
2022-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-02
F · Potential for more than minimal harm
2022-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-02
F · Potential for more than minimal harm
2022-10-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-12-02
F · Potential for more than minimal harm
2022-10-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-02
F · Potential for more than minimal harm
2022-10-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-02
F · Potential for more than minimal harm
2019-09-05
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2020-10-15
F · Potential for more than minimal harm
2019-09-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-15
F · Potential for more than minimal harm
2019-09-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-15
F · Potential for more than minimal harm
2019-09-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-15
F · Potential for more than minimal harm
2019-09-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-15
F · Potential for more than minimal harm
2019-09-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-10-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-13
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 2025-01-02
D · Potential for more than minimal harm
2024-11-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-02
F · Potential for more than minimal harm
2019-09-05
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 2019-10-15
Penalties and ownership
What sits behind the stars
Ownership
Harmon, Kathleen
5% Or Greater Direct Ownership Interest · Individual
Harmon, Kathleen
Corporate Director · Individual
Harmon, Kathleen
Corporate Officer · Individual
Kern, Sarah
Operational/Managerial Control · Individual
Rivera, Emmanuel
Operational/Managerial Control · Individual
St. Mary's Educational Institute At Cincinnati
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
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3-star overall rating with 2-star inspections with $45,503 in total fines with 1 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
Chamberlin Healthcare Center
Cincinnati, OH
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#3
Astoria Place Of Silverton
Cincinnati, OH
2-star overall rating with 1-star inspections with $15,887 in total fines with 9 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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