Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Marjorie P Lee Retirement Community during CMS and state inspections, most recent first.
Food items were stored improperly throughout the kitchen and resident refrigerators, including open and undated meats, dairy, juices, and frozen foods, as well as expired pudding mix and expired condiments. During meal prep and service, staff were observed without hair nets or beard guards, a SC had a personal cell phone and charging cord on a food prep counter, dark fuzz was hanging from the kitchen ceiling, and the same alcohol wipe was used to clean a thermometer between multiple foods. The HD stated there was no written policy on keeping personal items off food prep surfaces or on maintaining cleanliness of the kitchen prep area.
Pureed meal preparation was not followed as documented for a resident who required a mechanically altered diet and had severe cognitive impairment, significant wt loss, and hospice care. A cook added an unmeasured amount of water to a pureed philly steak sandwich instead of using broth, and the DSD confirmed there was no specific recipe available and that water should not have been used as the thinning agent.
A resident with severe cognitive impairment, total dependence for ADLs, incontinence, hospice care, and a sacral wound was not placed on EBP. Progress notes documented MASD and then an unstageable pressure ulcer on the sacrum, and staff confirmed no residents on the dementia unit were on EBP even though the resident had an open wound and met the facility’s EBP criteria.
A resident with severe cognitive impairment and left-sided hemiplegia, dependent on staff for care, was not positioned safely during in-bed care by a CNA. The CNA failed to call for help when the resident began sliding off the bed, instead moving the bed alone, which resulted in the resident falling and sustaining a hip fracture, scalp laceration, arm abrasion, and eye injury. The root cause was identified as human error and failure to follow proper procedures.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food items in a sanitary manner, including open and undated bags of plant-based meatballs and hamburger patties in the walk-in freezer, an open and undated half gallon of whole milk and open containers of prune juice and cranberry juice in the stand-up refrigerator, and expired single-serve cranberry juices dated 01/26/26 on the bottom shelf of the refrigerator. In the basement food storage area, two boxes of large bags of vanilla pudding mix were found with expiration dates of 08/01/2022, and staff stated the kitchen no longer used those mixes because pre-prepared vanilla pudding was purchased for residents. Additional food storage concerns were observed in the basement walk-in freezer, where a box of vegetable egg rolls, a box of beef hoagie patties, and a box of cod filets were all found in open, unsealed, and undated bags. In resident areas, two bowls of ice cream in the Amstein House resident refrigerator/freezer were covered but undated, and the Berghamer House resident refrigerator/freezer contained mayonnaise with an expiration date of 09/16/25 and apple butter with an expiration date of 11/19/25. The Berghamer freezer compartment also had no thermostat. During lunch preparation and service in the main kitchen, staff were observed without required hair coverings or beard guards, including a Specialty Cook preparing a pureed meal without a beard guard, a Dietary Services staff member without a beard guard, the Dining Services Director without a hair net, and another Dietary Services staff member without a hair net or beard guard. The same Specialty Cook had a personal cell phone and charging cord plugged into an outlet and sitting on the food preparation counter while preparing food. Surveyors also observed darkly colored fuzz hanging from the ceiling in several food preparation areas, and a Specialty Cook used the same alcohol wipe to clean a thermometer between checking multiple food items. Facility staff confirmed these observations, and the Hospitality Director stated the facility did not have written policies concerning keeping personal items off food preparation surfaces or maintaining cleanliness of the kitchen preparation area.
Pureed Meal Preparation Lacked Documented Recipe and Proper Thinning Agent
Penalty
Summary
The facility failed to prepare pureed foods in a way that maintained nutritive value and palatability for the only resident in the facility who required a pureed diet. Resident #13 was admitted with diagnoses including dementia with behavioral disturbance, malnutrition, urinary retention, anxiety disorder, depression, chronic constipation, atherosclerotic heart disease, and osteoporosis. The resident’s MDS assessment showed severe cognitive impairment, dependence for all activities of daily living, a mechanically altered diet, significant weight loss in the last quarter, and hospice care. During kitchen observation, Specialty Cook #76 was seen adding an unmeasured amount of water as a thinning agent while preparing a pureed philly steak sandwich with provolone, onions, and peppers. The cook confirmed that water was used and stated he was not following a documented recipe or procedure. The Dining Services Director stated beef broth should have been used instead of water and confirmed that water should not have been used. The DSD also confirmed there was no specific recipe available for direction on how to prepare the pureed philly steak sandwich with provolone, onions, and peppers. Facility policy stated pureed meals should be blended using broth, juice, or milk depending on the food item and to use the recipe for the proper amount of liquid.
Failure to Implement Enhanced Barrier Precautions for Resident With Open Wound
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were implemented for one resident with an open wound. Resident #13 was admitted with diagnoses including dementia with behavioral disturbance, malnutrition, urinary retention, anxiety disorder, depression, chronic constipation, atherosclerotic heart disease, and osteoporosis. The resident’s MDS showed severe cognitive impairment, dependence for all ADLs including bed mobility and transfers, bowel and bladder incontinence with dependence for incontinence care, a mechanically altered diet, significant weight loss in the prior quarter, and hospice care. Progress notes showed the resident had moisture associated skin damage and mechanical irritation on the left upper buttock/sacrum, and later an unstageable pressure ulcer over the sacrum measuring 3.5 cm by 0.1 cm with 75% slough and 25% granulation. The wound nurse stated the pressure ulcer was unavoidable due to the resident’s overall decline. Staff interviews revealed the dementia unit had no residents on enhanced barrier precautions, and the CTM confirmed the resident lived on that unit, had an open wound, and should have been on enhanced barrier precautions. The facility policy stated residents with wounds, indwelling medical devices, or ventilator dependence are required to be in enhanced barrier precautions.
Resident Injury Due to Improper Positioning and Lack of Assistance During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure the safe positioning of a resident during personal care in bed, resulting in actual harm. The resident, who had a history of left femur fracture, vascular dementia, left-sided hemiplegia, and was dependent on staff for all activities of daily living, required two-person assistance for transfers and repositioning, as well as the use of a mechanical lift. During morning care, the CNA attempted to turn the resident toward the wall to place a brief under her, but did not position her correctly, causing her legs to begin sliding off the bed. Instead of calling for assistance when the resident was in a compromised position, the CNA attempted to resolve the situation alone. The CNA unlocked and moved the bed to gain better access, which resulted in the resident's lower body falling off the bed due to gravity. The CNA then lowered the resident's upper body to the floor. The resident sustained a left hip fracture, a small scalp laceration, an abrasion to the right forearm, and a bruise with eye bleed to the left eye as a result of the fall. The incident was confirmed through medical record review, incident reports, root cause analysis, hospital records, and interviews with staff, the resident, and a visitor. The root cause analysis identified human error, specifically the CNA's failure to follow proper procedure for positioning and not seeking assistance when needed. The resident was subsequently sent to the hospital, where imaging confirmed a displaced fracture of the left femoral neck.
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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) |
|---|---|---|---|---|
| Beechwood Home For Incurables | 1.1 mi | ★★★★★ | 1 | 0 |
| Carecore At Margaret Hall | 1.5 mi | ★★★★★ | 12 | 0 |
| Arc At Cincinnati | 1.9 mi | ★★★★★ | 38 | 0 |
| Deupree Cottages | 1.9 mi | ★★★★★ | 0 | 0 |
| Lincoln Crawford Care Center | 2.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.