Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MARJORIE P LEE RETIREMENT COMMUNITY

CINCINNATI, OH · 88 certified beds · Last Life Safety survey January 29, 2026

CMS Certification Number 365802 · first certified July 1990

Ownership

Operated by EPISCOPAL RETIREMENT HOMES, INC. · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within OH

17 citations — more than 53% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens September 2027 — about 12 months from now. This facility’s last Life Safety survey was January 2026. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	17
Median facility in OH	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
December 28, 2019	4
July 20, 2023	7
January 29, 2026	6

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	2	2026-01-29
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2026-01-29
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2026-01-29
K-0324	Provide properly protected cooking facilities.	2	2026-01-29
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2026-01-29
K-0281	Install proper backup exit lighting.	1	2019-12-28
K-0341	Install a fire alarm system that can be heard throughout the facility.	1	2023-07-20
K-0363	Install corridor and hallway doors that block smoke.	1	2019-12-28

What the citations cover

Citations by CMS category

Smoke Deficiencies 10
Egress Deficiencies 4
Services Deficiencies 2
Gas, Vacuum, and Electrical Systems Deficiencies 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	10
Egress Deficiencies	4
Services Deficiencies	2
Gas, Vacuum, and Electrical Systems Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 29, 2026 — 6 citations

Citations issued on January 29, 2026
Tag	What the surveyor checks	Status
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (March 20, 2026)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (March 20, 2026)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (March 20, 2026)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 20, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 20, 2026)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (March 20, 2026)

July 20, 2023 — 7 citations

Citations issued on July 20, 2023
Tag	What the surveyor checks	Status
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 13, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 13, 2023)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (October 13, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 13, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 13, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (October 13, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 13, 2023)

December 28, 2019 — 4 citations

Citations issued on December 28, 2019
Tag	What the surveyor checks	Status
K-0225	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	Deficient, Provider has date of correction (February 12, 2020)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (February 12, 2020)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 12, 2020)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (February 12, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.