Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cottingham Retirement Community during CMS and state inspections, most recent first.
Food was not stored and prepared under sanitary conditions in the kitchen. Surveyors found moldy, opened, and undated bread in dry storage; multiple undated or outdated prepared foods in the walk-in refrigerator; and an opened, undated bag of frozen bread sticks in the freezer. They also observed dirty ceiling tiles and dust-coated vents in the main kitchen, along with missing refrigerator/freezer temperature log entries despite policy requiring temps to be checked and recorded twice daily.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions policy during wound care for a resident with an infected diabetic foot ulcer, when an RN entered the room and prepared to perform a dressing change without donning required PPE, despite the resident being on EBP for a left foot wound. The review also showed that the only Legionella-related document was a generic water management guide that did not specify any facility-specific control measures, and the Administrator confirmed there were no defined actions in place to manage Legionella risk.
Incomplete Discharge Summary: The facility failed to complete a resident’s discharge summary. The resident had multiple chronic diagnoses, was cognitively intact, and required assistance with several ADLs. The discharge summary was left incomplete with blank sections for discharge destination, home health services, DME, social service history, and dietary information, and the DON verified it had not been completed.
A resident with multiple neurologic and chronic conditions, including moderate cognitive impairment, had hospice elected, but the facility did not have a clear hospice admission date or any hospice plan of care or progress notes in the chart. The SSD, RN, and Administrator were unaware of the missing hospice documentation, and the resident could not explain what hospice services were being provided, while the hospice nurse stated services were being delivered and documented in the hospice EMR.
A resident with multiple respiratory and other chronic diagnoses was observed receiving oxygen at 2 lpm via concentrator without physician orders in place. An LPN confirmed the resident returned from the hospital on oxygen with instructions to wean as appropriate, and also confirmed there was no oxygen-in-use sign posted on the room door. Facility policy required oxygen to be given under physician orders and warning signs to be placed where oxygen is in use.
Medications were not stored appropriately when two pills and an empty medication cup were found on the floor beside a resident’s bed. The resident had dementia, chronic venous hypertension, Type II DM, and neuropathy, and was receiving gabapentin and carvedilol as ordered. An ADON identified the pills as those medications and stated they should not have been on the floor; the facility policy required non-refrigerated meds to be stored in a medication cart or other designated area.
A resident with dementia, CKD, DM2, and muscle weakness had severe cognitive impairment, required extensive assistance with ADLs, and had frequent incontinence, care rejection, and wandering. After the resident’s representative consented to a pneumococcal vaccine, the record showed no documentation that it was ever administered, and the ADON confirmed the vaccine had still not been given and was unsure what delayed its delivery.
Delay in COVID-19 Vaccine Administration After Consent: A resident with dementia, weakness, and multiple care needs had a family representative consent to the COVID-19 vaccine, but the vaccine was not administered by the time of survey review. The ADON confirmed the consent and stated the delay in obtaining and providing the vaccine from the pharmacy was unknown.
Nonfunctional Resident Call Light: A resident with multiple chronic conditions, including dementia and CHF, had a call light that was not working. The resident reported the issue had been ongoing for some time and had told staff multiple times. During observation, the resident activated the call light, but the hallway indicator did not light up. A CNA confirmed the call system was not functioning and stated it had not worked for several days.
Staff, including RNs, LPNs, and CNAs, entered rooms of COVID-19 positive residents without wearing required PPE such as N-95 respirators, gowns, gloves, and face shields, instead using only surgical masks while providing care and delivering meals. Staff interviews confirmed non-compliance with infection control protocols, despite facility policy and signage requiring full PPE for contact and droplet precautions.
The facility did not ensure that physician-ordered laboratory tests were completed for two residents with complex medical conditions. Despite orders for multiple labs, only some were completed, and several were not obtained or on file, as confirmed by the DON. This failure was contrary to facility policy requiring staff to process and arrange for all ordered diagnostic testing.
A resident under hospice care was allegedly neglected by a nurse who refused to administer medications. Despite the facility's policy requiring suspension of staff pending abuse investigations, the nurse continued to work during the investigation. The incident was reported by the resident's daughter, leading to a hospital transfer. The facility's administrator confirmed the oversight.
The facility failed to maintain proper infection control measures during care for two residents. A CNA did not change gloves or perform hand hygiene during incontinence care for a resident with multiple health conditions, violating the facility's hand hygiene policy. Additionally, the CNA did not wear a gown during catheter care for another resident under Enhanced Barrier Precautions, contrary to the facility's policy. These deficiencies were identified during a complaint investigation.
Food Storage, Sanitation, and Temperature Log Deficiencies
Penalty
Summary
Food was not stored and prepared under sanitary conditions in the main kitchen. During observation of the dry food storage area, an opened, undated package of sandwich buns was found with mold growing on one of the buns, along with an opened, undated loaf of white bread. In the walk-in refrigerator, surveyors observed a loosely covered cart of pre-prepared foods dated 02/03/26 that contained individual prepared salads, pumpkin pie, coconut cream pie, and pears. Next to it was an undated loosely covered smaller cart containing diced ham, onions, cooked omelets, and uncooked bacon, and there was also an undated covered container of pre-made chili on a shelf. In the walk-in freezer, an open box contained an opened, undated bag of frozen bread sticks. The Dietary Supervisor and Dietary Director verified the items and the outdated or undated foods were discarded. Surveyors also observed dirty kitchen ceiling tiles and three of four vents with dark dust coating much of the vent in the main kitchen. The Dietary Supervisor verified the ceiling tiles were dirty and stated maintenance was responsible for cleaning the ceiling tiles and vents. The Dietary Director and Maintenance Director also verified the ceiling tiles and vents were dirty and needed cleaning. Review of refrigerator and freezer temperature logs showed missing temperature logs for 09/25/25 and 10/26/25 through 10/31/25, as well as a missing temperature entry on 10/25/25. Facility policy required refrigeration and freezer temperatures to be monitored twice daily and recorded, and the food safety policy required food to be protected from contamination and opened food items to be marked with an open date.
Failure to Follow Enhanced Barrier Precautions and Lack of Legionella Water Management Plan
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy during wound care and its failure to develop and implement a specific water management plan for Legionella. Resident #17, who was severely cognitively impaired and had moderate depression, had multiple diagnoses including Alzheimer’s disease, chronic kidney disease, diabetic retinopathy, and a kidney transplant, and had an infected diabetic foot ulcer on the left foot requiring daily wound care with normal saline cleansing, calcium alginate, and a bordered foam dressing. The resident’s care plan documented that EBP had been implemented due to the infected left foot wound, and the facility’s EBP policy required gown and glove use for any wound care or skin opening requiring a dressing. During observation, an RN gathered wound care supplies, placed them on the bedside table, left and re-entered the room without any PPE, and prepared to remove the resident’s foot dressing. When questioned, the RN stated she believed the resident was on EBP but thought PPE was only required for direct patient care and was unsure if wound treatment qualified, indicating a failure to don required gown and gloves before performing wound care. The deficiency also includes the facility’s failure to have a functional water management plan addressing Legionella risk. The only document provided, titled “Policy and Procedure: Water Management Plan – Legionella,” was a general guide on developing a water management plan and listed commonly used control measures but did not specify what actions the facility itself was taking to reduce the risk of Legionella. In an interview, the Administrator confirmed that this document was the only water management plan available and was unable to provide any information about actual measures used by the facility, demonstrating that no specific, implemented plan for Legionella control was in place. This non-compliance was investigated under Complaint Number 2718794.
Incomplete Discharge Summary
Penalty
Summary
The facility failed to ensure discharge summaries were completed for one resident discharged from the facility. The closed medical record showed the resident was admitted on 11/07/25 and discharged on 02/03/26, with diagnoses including Parkinson's disease without dyskinesia with fluctuations, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder, repeated falls, bipolar disorder, cerebrovascular disease, conversion disorder with seizures or convulsions, encephalopathy, other symbolic dysfunctions, and chronic viral hepatitis B without delta-agent. The admission MDS indicated the resident was cognitively intact and required setup assistance for eating, oral hygiene, and personal hygiene, and partial/moderate assistance for toileting, bathing, dressing, bed mobility, and transfers. Review of the discharge summary dated 01/30/26 showed the assessment had not been completed, and the sections for discharge destination, home health services, durable medical equipment, social service history, and dietary information were blank. A progress note documented that the resident was discharged to the attached assisted living facility, and the DON verified on interview that the discharge summary had not been completed.
Failure to Coordinate Hospice Care Documentation
Penalty
Summary
The facility failed to ensure care was coordinated with the hospice provider for one resident who had diagnoses including cerebral infarction, cognitive communication deficit, aphasia, right-sided hemiplegia, unspecified convulsions, stenosis of the right cerebral artery, diabetes, hyperlipidemia, hypertension, and a history of transient ischemic attacks. The resident’s MDS assessment showed moderate cognitive impairment. The medical record showed a hospice referral, and a care conference was held with the resident’s family, who believed hospice had already been initiated. The Social Service Director confirmed with the hospice nurse that the resident had elected hospice services, but the facility record did not contain a clear date of admission to hospice. Review of the resident’s hospice binder showed only an initial order sheet and hospice contact information, with no plan of care, progress notes, or other documentation of hospice services being provided at the facility. The resident stated hospice staff had seen her at the facility but could not explain who came, how often, or what services were provided. A staff nurse was unsure whether the resident was receiving hospice services and had not recently seen hospice staff. The Social Service Director and Administrator were unaware that no hospice plan of care or progress notes were available in the facility record, while the hospice nurse stated hospice nursing services were provided weekly and a hospice aide came weekly for showers, with documentation kept in the hospice EMR.
Missing Oxygen Orders and Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident receiving oxygen therapy. Resident #56, admitted on 02/14/2023 with diagnoses including multiple sclerosis, asthma, acute and chronic respiratory failure with hypoxia, morbid obesity, anxiety disorder, and major depressive disorder, had no physician orders in the medical record for oxygen administration. The annual MDS indicated the resident had no cognitive impairment. Despite the lack of orders, observations on 02/10/26 and 02/11/26 showed the resident receiving oxygen at 2 lpm via an oxygen concentrator. During interview on 02/11/26, an LPN confirmed the resident was on oxygen therapy at 2 lpm, verified there were no physician orders for oxygen, and stated the resident returned from the hospital on 2 lpm of oxygen with instructions to wean as appropriate. Observations also showed there was no oxygen-in-use signage posted on the resident’s door, and the LPN confirmed the sign was missing. Facility policy stated oxygen is administered under physician orders and warning signs must be placed on the door where oxygen is in use.
Medications Found on Resident Room Floor
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional principles when two medications were found on the floor beside a resident’s bed in his room. Resident #11 was admitted with diagnoses including dementia, chronic venous hypertension, Type II diabetes, and neuropathy, and the quarterly MDS indicated minimally impaired cognition. Physician orders showed the resident received gabapentin 300 mg, three capsules by mouth twice daily for neuropathy, and carvedilol 3.125 mg, one tablet by mouth twice daily for hypertension, and the MAR showed both medications were administered as ordered on the two days reviewed. During observation of the resident’s room, surveyors found two pills and an empty medication cup on the floor beside the bed. The ADON picked up the items, stated the pills were on the resident’s room door, and said she would attempt to identify them. The ADON later identified the pills as gabapentin and carvedilol and stated she could confirm which medication administration they were from, but verified the medications should not have been on the floor. The facility’s medication storage policy stated that medications not requiring refrigeration or freezing were to be stored in a medication cart or other designated area.
Delayed Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure timely provision of a pneumococcal vaccine after the resident’s representative consented to vaccination. Resident #19 was admitted on 08/06/2025 and had diagnoses including unspecified dementia, chronic kidney disease, type 2 diabetes mellitus without complications, and muscle weakness. The quarterly MDS assessment showed severe problems with thinking and memory, assistance needs for eating, ambulation, oral hygiene, dressing, hygiene, transfers, and toileting, along with frequent bowel and bladder incontinence, rejection of care, and wandering behaviors one to three days a week. The resident’s son and daughter-in-law consented on 09/24/2025 for the pneumococcal vaccine, but review of the record on 02/12/2026 showed no documentation that the vaccine had been administered. The ADON confirmed the consent and stated the resident had not received the vaccine as of 02/12/2026, and reported that corporate office orders vaccines from the pharmacy but was unsure what delayed delivery and provision of the vaccine.
Delay in COVID-19 Vaccine Administration After Consent
Penalty
Summary
The facility failed to ensure timely provision of the COVID-19 vaccine to a resident after consent was obtained. Resident #55 was admitted on 08/05/25 with diagnoses including nondisplaced lateral mass fracture of the first cervical vertebra with delayed healing, muscle weakness, unspecified dementia, and anxiety disorder. The quarterly MDS indicated the resident had moderate problems with thinking and memory, was independent in wheelchair mobility, required setup assistance for eating, supervision for sit-to-stand and transfers, moderate assistance with oral hygiene, toileting, bathing, upper and lower body dressing, and personal hygiene, and was always incontinent of bladder and frequently incontinent of bowel. The resident's daughter, acting as representative, consented to the COVID-19 vaccine on 09/24/25, but the medical record showed no indication that the vaccine had been administered by 02/12/26. The ADON confirmed the consent and verified that the resident still had not received the vaccine, stating that the corporate office orders vaccines from the pharmacy and that the delay in delivery and provision was unknown.
Nonfunctional Resident Call Light
Penalty
Summary
The facility failed to ensure that a working call system was available in a resident's bathroom and bathing area, affecting Resident #12. Resident #12's medical record showed diagnoses including Alzheimer's disease, dysphagia, glaucoma, congestive heart failure, atrial fibrillation, heart disease, dementia without behaviors, osteoporosis, benign prostatic hyperplasia, anxiety disorder, edema, gastro-esophageal reflux disease, and hypertension. The resident's MDS assessment dated 01/05/26 indicated mild cognitive impairment, wheelchair use for mobility, set-up assistance for eating, and moderate assistance with toileting, oral hygiene, dressing, and personal hygiene. During interview on 02/10/26 at 2:39 P.M., Resident #12 stated the call light had not been working for quite some time and that he had alerted staff on multiple occasions. At the same time, observation showed the resident pushed the call light, but the hallway light did not activate to indicate assistance was needed. CNA #344 confirmed the hallway light was not working when the call light was activated, checked that it was plugged in, and pushed it again with the same result. CNA #344 stated they were not aware the call light was not functioning properly and added that it had not worked for the last several days. The facility's call light policy dated August 2022 stated staff were to notify maintenance if a call light was not functioning.
Failure to Implement COVID-19 Precautions and PPE Use
Penalty
Summary
The facility failed to implement appropriate COVID-19 infection prevention and control precautions for residents who tested positive during an outbreak. Medical record review identified 24 residents who were COVID-19 positive at the start of the outbreak. Multiple direct observations revealed that staff, including registered nurses, licensed practical nurses, and certified nursing assistants, entered rooms of COVID-19 positive residents without donning the required personal protective equipment (PPE) such as N-95 respirators, gowns, gloves, and face shields. Instead, staff were observed wearing only surgical masks while performing tasks such as administering medications and delivering meal trays. Interviews with the involved staff confirmed their lack of compliance with PPE protocols, with some staff acknowledging they forgot to wear the appropriate equipment. Facility policy and posted signage required the use of full PPE for contact and droplet precautions in rooms of COVID-19 positive residents. The failure to follow these protocols was observed on several occasions and verified through staff interviews, affecting the infection control measures for all 58 residents in the facility.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory values were completed as ordered by the physician for two out of three residents reviewed. For one resident with multiple diagnoses including dementia, pressure ulcers, diabetes, and cerebral atherosclerosis, a wound care nurse practitioner ordered several labs (CBC, CMP, albumin, prealbumin, transferrin, and hemoglobin A1c). While the CMP was completed, the other ordered labs were not obtained or on file, as confirmed by the Director of Nursing (DON). Another resident with a history of pseudobulbar affect, stroke, depression, Alzheimer's disease, diabetes, hyperlipidemia, hypertension, anxiety, chronic kidney disease, and other cerebrovascular disease also had several labs ordered (CBC, CMP, TSH, A1c, lipid panel, ferritin, B12, and vitamin D) to be collected on a specified lab day. None of these labs were collected or on file, as verified by the DON. The facility's policy required staff to process test requisitions and arrange for testing, but this was not followed for these residents.
Failure to Suspend Staff During Abuse Investigation
Penalty
Summary
The facility failed to suspend a staff member pending an abuse investigation, which affected a resident under hospice care. The resident, who was severely cognitively impaired and dependent on staff for various needs, was allegedly neglected by a registered nurse who refused to administer medications. The resident's daughter reported the incident, leading to the resident being transferred to a hospital. Despite the allegation, the nurse continued to work during the investigation period. The facility's policy mandates the immediate removal of employees accused of abuse or neglect pending investigation results. However, the registered nurse in question was not suspended and continued to work full shifts during the investigation. The facility's administrator confirmed the oversight, acknowledging that the investigation began after the incident was reported and concluded without the nurse being suspended. This failure to follow policy was identified during a complaint investigation.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control measures during incontinence care for two residents. Resident #37, who had chronic obstructive pulmonary disease, type two diabetes mellitus, and congestive heart failure, was observed receiving incontinence care from CNA #100. The CNA performed hand hygiene and applied gloves before starting care but did not change gloves or perform hand hygiene during the procedure. The CNA used the same gloves to clean the resident's perineal area, which was soiled with urine and feces, and then proceeded to clean the resident's backside. After completing the care, the CNA adjusted the resident in bed with the soiled gloves before finally removing them and performing hand hygiene. This was in violation of the facility's hand hygiene policy, which required hand hygiene before donning gloves and immediately after removing them. Additionally, Resident #41, who had severe cognitive impairment and an indwelling catheter, was observed receiving catheter care from the same CNA. The resident was under Enhanced Barrier Precautions (EBP) due to the catheter, which required the use of a gown and gloves during care. However, the CNA did not wear a gown while providing care, contrary to the facility's EBP policy. This policy mandated the use of gowns and gloves during high-contact resident care activities, including urinary catheter care, to reduce the transmission of multi-drug-resistant organisms. These deficiencies were identified during a complaint investigation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookwood Care Center | 1.2 mi | ★★★★★ | 16 | 0 |
| Advanced Health Care Of Cincinnati | 3 mi | ★★★★★ | 1 | 0 |
| Meadowbrook Care Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Chesterwood Atc | 4.2 mi | ★★★★★ | 0 | 0 |
| Glendale Place Care Center | 4.4 mi | ★★★★★ | 15 | 0 |
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