Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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.
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 | — | 0 | 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 August 2026) and official state health department websites.