Cycle 1
Health 2024-06-06 · Fire 2024-06-06
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cincinnati, OH
Twin Lakes
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
9840 Montgomery Road, Cincinnati, OH
(513) 247-1301
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
43
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-01-01
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
1.46
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.10
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.38
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.56
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.68
CMS adjusted RN staffing hours
Adjusted total hours
5.89
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,674
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.87
Composite VBP score used to determine payment impact.
Payment multiplier
1.0098
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.07
Baseline 18.37% · Performance 20.94% · Measure score 1.07 · Achievement 1.07 · Improvement 0
Healthcare-associated infections
7.72
Baseline 5.77% · Performance 5.53% · Measure score 7.72 · Achievement 7.72 · Improvement 2.63
Total nurse turnover
3.16
Baseline 58.97% · Performance 50.77% · Measure score 3.16 · Achievement 3.16 · Improvement 1.90
Adjusted total nurse staffing
10
Baseline 5.73 hours · Performance 5.95 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.88% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 289 · Observed rate 10.03% · Lower 95% interval 9.41% |
| Discharge to community | 56.44% |
50.57%
5.9 pts better
|
Better than the National Rate · Eligible stays 287 · Observed rate 56.79% · Lower 95% interval 50.85% |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 146 · Denominator 146 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 146 |
| Discharge self-care score | 38.89% |
53.69%
14.8 pts worse
|
Numerator 49 · Denominator 126 |
| Discharge mobility score | 54.76% |
50.94%
3.8 pts better
|
Numerator 69 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 146 · Adjusted rate 0.84% |
| Healthcare-associated infections requiring hospitalization | 5.53% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 2.34% · Lower 95% interval 2.93% |
| Staff COVID-19 vaccination coverage | 4.71% |
8.2%
3.5 pts worse
|
Numerator 4 · Denominator 85 |
| Staff flu vaccination coverage | 14.71% |
42%
27.3 pts worse
|
Numerator 15 · Denominator 102 |
| Discharge function score | 46.83% |
56.45%
9.6 pts worse
|
Numerator 59 · Denominator 126 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 102 · Denominator 102 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 20 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · 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 | 96.3% |
94.5%
1.8 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 4.2% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
26.1%
26.1 pts better
|
11.4%
11.4 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 who lose too much weight | 1.5% |
6.2%
4.7 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.2% |
25.4%
15.8 pts worse
|
19.6%
21.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 41.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
11.5%
2.8 pts worse
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.6% |
7.7%
22.9 pts worse
|
16.3%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.8% |
6.2%
27.6 pts worse
|
14.9%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.8% · 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 · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
0.5%
2.5 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
21.7%
3.5 pts better
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 26.5% · Q3 20.9% · Q4 15.3% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
3.7%
2.8 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
78.1%
19.6 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.9% · Q4 94.9% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.5% |
12.5%
8 pts better
|
12.0%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 4.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
75.6%
18.2 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
25.1%
6.3 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 15.1% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-08 · Fire 2021-07-08
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-03-07 · Fire 2019-03-07
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-01
F · Potential for more than minimal harm
2021-07-08
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-07-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-07-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-07-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-20
E · Potential for more than minimal harm
2021-07-08
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 2021-08-20
E · Potential for more than minimal harm
2021-07-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-20
F · Potential for more than minimal harm
2019-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2021-07-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-08
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 2021-08-20
Penalties and ownership
What sits behind the stars
Ownership
Anderson, Todd
Corporate Director · Individual
Ansari, Saba
Contracted Managing Employee · Individual
Bowersox, James
Corporate Director · Individual
Bowersox, James
Corporate Officer · Individual
Bowersox, James
W-2 Managing Employee · Individual
Brown, Denise
W-2 Managing Employee · Individual
Brueshaber, Larry
Corporate Director · Individual
Burgess, Douglas
Corporate Director · Individual
Hildal, Robyn
Corporate Director · Individual
Hildal, Robyn
Corporate Officer · Individual
Mcdonald, Kenneth
W-2 Managing Employee · Individual
Mcquinn, Scott
Corporate Director · Individual
Mcquinn, Scott
Corporate Officer · Individual
Mcquinn, Scott
W-2 Managing Employee · Individual
Thorpe, Joseph
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Montgomery Care Center
Cincinnati, OH
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Blue Ash Care Center
Cincinnati, OH
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Meadowbrook Care Center
Cincinnati, OH
1-star overall rating with 1-star inspections with 23 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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