The Enclave of Springboro — Ohio Facility Report

Inspections on file

Deficiencies cited

Visits with none

Substandard care

Immediate jeopardy

The most recent inspection on file for The Enclave of Springboro took place on March 14, 2026. Across the 14 inspections published by the Ohio Department of Health, surveyors cited 9 deficiencies.

A deficiency is a rule the surveyor found the facility was not meeting. Ohio inspects against two rule books at once, so most findings carry a federal code and an Ohio code for the same problem; each is counted once here, the way the state counts it. Correction dates are the state's confirmation that the issue was fixed.

This report reproduces what Ohio publishes and nothing else. Of the 14 inspections listed, the state publishes the surveyor's written findings for 4; for the other 10 it publishes only the date, the type of visit and the number of deficiencies - 10 of which found none.

Facility Details

Ohio license number

#2712R

County

Warren

Administrator

Kristin Roark

Director of nursing

Rebecca Calhoun

Phone

(937) 748-1919

Ownership

For Profit - Corporation

Inspections

14 on file · 9 deficiencies

March 14, 2026Complaint survey1 deficiency▼

R-0559Procure, store, prepare, distribute and serve foodsOhio citation▼

What the surveyor found

Based on observations, staff interviews, and policy review, the facility failed to ensure food in the kitchen was stored and prepared in a manner to prevent contamination and spoilage. This had the potential to affect all 127 residents residing in the facility. The facility census was 127.

Findings include:

Observations and interviews on 03/14/26 from 9:15 A.M. to 9:32 A.M. of the kitchen during the initial tour revealed two kitchen staff were not wearing hair nets in the kitchen while preparing food. Regional Culinary Director (RCD) #399 confirmed workers in the kitchen were not wearing hair nets and should be. Observations also revealed a scoop was left in the ice machine, and two large trash cans did not have lids. RCD #399 confirmed the ice scoop should not be left in the ice machine and that the two large trash cans did not have lids. Observations revealed a large food storage container of mixed fruit had been sitting out in the prep area without a way to keep it at the correct temperature. RCD #399 confirmed the fruit had been sitting out prior to the start of the kitchen tour.

Observations and interviews on 03/14/26 from 11:47 A.M. to 12:08 P.M. of the kitchen during lunch service further revealed five additional employees walking through the kitchen without hair nets. RCD #399 confirmed staff were not wearing hair nets. Observation of food temperature checks revealed RCD #399 tore a corner of the sanitizing wipe packet and stabbed the thermometer through the packet and pull it back through. RCD #399 confirmed this was his method for cleaning the thermometer between each food item. Further observation of the kitchen revealed one ceiling tile above the serving area missing and water pipes exposed water pipes. Water was leaking from one of the pipes into a bucket on the floor. An open large food storage container of iceberg lettuce was on the counter surface under the exposed ceiling. RCD #399 confirmed the ceiling had been leaking since earlier in the week when the area got heavy rainfall. RCD #399 confirmed open food containers should not be near the ceiling leak.

Review of the policy titled, Bridge Appearance Standards

Rule

Ohio Administrative Code - residential care rules

December 3, 2025Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

July 23, 2025Licensure survey5 deficiencies▼

R-0393Tuberculosis control plan and risk assessmentOhio citation▼

What the surveyor found

Based on observation, interview, and record review, the facility failed to assess and maintain record of employee tuberculosis (TB) immunization status. This had the potential to affect all residents residing in the facility. The census was 117. Findings include: Review of personnel files for employees Licensed Practical Nurse (LPN) #171 and Server #153 revealed both employee files had no record of updated annual TB questionnaire. Interview on 07/23/25 at 2:30 P.M. with Administrative Assistant #203 verified the facility had not received a completed annual TB screening form from employees LPN #153 and Server #171. AA #203 stated the facility had been in the process of switching to electronic documentation of this form, but no electronic documentation of the completed form was available for either of these employees on the date of the survey. Review of undated facility policy titled, Tuberculosis Control PlanBased on observation, interview, and record review, the facility failed to assess and maintain record of employee tuberculosis (TB) immunization status. This had the potential to affect all residents residing in the facility. The census was 117.

Findings include:

Review of personnel files for employees Licensed Practical Nurse (LPN) #171 and Server #153 revealed both employee files had no record of updated annual TB questionnaire.

Interview on 07/23/25 at 2:30 P.M. with Administrative Assistant #203 verified the facility had not received a completed annual TB screening form from employees LPN #153 and Server #171. AA #203 stated the facility had been in the process of switching to electronic documentation of this form, but no electronic documentation of the completed form was available for either of these employees on the date of the survey.

Review of undated facility policy titled, Tuberculosis Control Plan

Rule

Ohio Administrative Code - residential care rules

R-0559Procure, store, prepare, distribute and serve foodsOhio citation▼

What the surveyor found

Based on observation, staff interview, and review of facility food safety policies, the facility failed to protect food from potential contamination and spoilage. This finding had the potential to affect all residents residing in the facility. The census was 117. Findings include: Observations during the kitchen tour on 07/23/25 between 10:52 A.M. and 10:55 A.M. revealed the following: Observation at 10:52 A.M. revealed raw chicken breasts stored directly above raw ground beef in walk-in cooler. This finding was verified by Director of Culinary Services #175 at the time of observation. Observation at 10:53 A.M. revealed raw tilapia kept past the marked discard date of 07/20/25 in the walk-in cooler. This finding was verified by Director of Culinary Services #175 at the time of observation. Observation at 10:54 A.M. revealed an opened bag of Canadian bacon stored uncovered with no date marking in the walk-in cooler. This finding was verified by Director of Culinary Services #175 at the time of observation. Observation at 10:55 A.M. revealed frozen turkey burger patties stored uncovered in the walk-in freezer. This finding was verified by Director of Culinary Services #175 at the time of observation. Review of the facility policy titled, Food and Supply Storage ProceduresBased on observation, staff interview, and review of facility food safety policies, the facility failed to protect food from potential contamination and spoilage. This finding had the potential to affect all residents residing in the facility. The census was 117.

Findings include:

Observations during the kitchen tour on 07/23/25 between 10:52 A.M. and 10:55 A.M. revealed the following:

Observation at 10:52 A.M. revealed raw chicken breasts stored directly above raw ground beef in walk-in cooler. This finding was verified by Director of Culinary Services #175 at the time of observation.

Observation at 10:53 A.M. revealed raw tilapia kept past the marked discard date of 07/20/25 in the walk-in cooler. This finding was verified by Director of Culinary Services #175 at the time of observation.

Observation at 10:54 A.M. revealed an opened bag of Canadian bacon stored uncovered with no date marking in the walk-in cooler. This finding was verified by Director of Culinary Services #175 at the time of observation.

Observation at 10:55 A.M. revealed frozen turkey burger patties stored uncovered in the walk-in freezer. This finding was verified by Director of Culinary Services #175 at the time of observation.

Review of the facility policy titled, Food and Supply Storage Procedures

Rule

Ohio Administrative Code - residential care rules

R-0564Kitchen and dining areas clean and sanitary; transporting meals; garbageOhio citation▼

What the surveyor found

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen and failed to place food scraps and trash in garbage cans with tight fitting lids. This finding had the potential to affect all residents residing in the facility. The census was 117.

Findings include:

1. Observation on 07/23/25 at 10:30 A.M. revealed three uncovered garbage cans in food preparation areas of the kitchen with food scraps in the containers. One receptacle was found at the end of the main food service line uncovered, and two other uncovered receptacle were observed in the food preparation area in front of the walk-in cooler. This finding was verified by Culinary Services Director #175 at the time of observation. Director of Culinary Services #175 proceeded to retrieve lids from dry storage area and covered the garbage cans at the time of observation.

2. Observation on 07/23/25 at 10:37 A.M. revealed significant accumulation of food debris and food items on the floor of the prep cooler next to the oven on the main food service line. Food items observed loose inside this cooler included uncooked/frozen chicken tenders, french fries, and burger patties. This finding was verified by Culinary Services Director #175 at the time of observation.

Interview with Culinary Services Director #175 at 10:37 A.M. on 07/23/25 revealed the prep cooler with loose food items throughout the inside of the cooler was on his list of kitchen areas to clean, but it had not yet been done.

Rule

Ohio Administrative Code - residential care rules

R-0615Fire drill requirementsOhio citation▼

What the surveyor found

Based on review of monthly fire drill reports and staff interviews, the facility failed to maintain documentation of resident evacuations for monthly fire drills. The facility census was 117.

Findings include:

Review of facility fire drills dated 08/28/24, 09/19/24, 10/18/24, 11/25/24, 12/23/24, 01/24/25, 02/25/25, 03/24/25, 04/21/25, 05/28/25, 06/26/25, and 07/15/25 revealed no documentation of residents evacuated during any fire drills.

During an interview on 07/23/25 at 2:24 P.M., Maintenance #176 stated the facility performed resident evacuations on fire drills but verified he had no documentation to support that resident evacuations were completed.

Rule

Ohio Administrative Code - residential care rules

R-0626Carbon Monoxide detector requirementOhio citation▼

What the surveyor found

Based on observations, staff interviews, and review of Ohio Fire Code Section 915, the facility failed to ensure carbon monoxide detectors were placed in rooms containing fuel-burning devices. This had the potential to affect all residents. The facility census was 117.

Findings include:

Observations made on 07/23/25 from 12:09 P.M. to 12:19 P.M. revealed the facility did not have carbon monoxide detectors placed near the 2nd floor gas-burning fireplace or in the main floor or second floor laundry rooms near gas dryers.

During interviews conducted on 07/23/25 from 12:110 P.M. to 12:20 P.M., Maintenance #176 verified there were no carbon monoxide detectors visible near the second-floor fireplace or in the laundry rooms located on the main floor and second floor near gas dryers.

Review of Ohio Fire Code Section 915 dated 02/2018 revealed Carbon Monoxide (CO) detection is required in any room containing a fuel-burning appliance or fuel-burning fireplace.

Rule

Ohio Administrative Code - residential care rules

July 10, 2025Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

December 13, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

July 11, 2024Licensure survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

May 6, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

January 22, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

August 30, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

June 26, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

May 3, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

March 28, 2023Complaint survey1 deficiency▼

R-0391Resident incidents and log; identify resident upon requestOhio citation▼

What the surveyor found

Based on medical record review, staff interview, review of the fall and incident log, and policy review, the facility failed to maintain an updated incident and fall log. In addition, the facility failed to complete the fall investigation report or a fall incident report. This affected three residents (#50, #89, and #113) of three residents reviewed for falls. The facility census was 110.

Findings include:

1. Review of the medical record revealed Resident #50 was admitted to the facility on 11/30/21. Diagnoses included chronic pulmonary disease, and congestive heart failure. Resident #50 was cognitively intact.

Review of the progress note dated 02/24/23 for Resident #50 documented by Licensed Practical Nurse (LPN) # 205 revealed Resident #50's son was notified of the residents earlier fall. Resident #50's son said the resident preferred to go to a specific hospital for evaluation. Resident #50 was sent to the hospital for evaluation due to the fall.

Review of the fall and incident log dated from 12/28/22 to 03/28/23 revealed Resident #50's fall on 02/24/23 was not documented on the log.

Review of the medical record for Resident #50 revealed there was no incident or fall investigation report completed for the resident's documented fall on 02/24/23.

Interview on 03/28/23 at 1:10 P.M., LPN #205 said Resident #50 had an unwitnessed fall on 02/24/23 and the resident was sent to the emergency room due to an unwitnessed fall and hitting her head.

Interview on 03/28/23 at 1:50 P.M., the Wellness Director verified Resident #50's fall incident and fall investigation report was not completed.

2. Review of the medical record revealed Resident #89 was admitted to the facility on 06/30/21. Diagnoses included dementia, coronary artery disease, and Alzheimer's disease. Resident #89 was admitted to hospice on 03/22/23.

Review of an incident report dated 03/13/23 revealed Resident #89 had a fall on 03/13/23.

Further review of the medical record revealed a fall investigation report for Resident #89's fall on 03/13/23 was not completed.

Interview on 03/28/23 at 1:45 P.M., the Wellness Director verified Resident #89 had a fall incident report completed on 03/13/23 for a fall, however had not completed the fall investigation report.

3. Review of the closed medical record revealed Resident #113 was admitted to the facility on 01/24/22. Resident #113 had diagnosis of liver disease, cognitive disorder, and irritable bowel syndrome. Resident #113 died in the facility on hospice on 03/11/23.

Interview on 03/28/23 at 2:50 P.M., the Wellness Director verified Resident #113 falls dated 01/22/23 and 02/11/23 had a fall incident report, however no fall investigation form was completed. The Wellness Director said the nurse at times would only complete the fall incident report and often forget to complete a fall investigation form. The Wellness Director said she had educated staff many times on the use of the fall incident and investigation forms.

Review of the policy titled Fall Response

Rule

Ohio Administrative Code - residential care rules

December 6, 2022Licensure survey · listed in Ohio's index; no findings report publishedNo deficiencies▼

✅

No deficiencies cited

Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.

September 9, 2022Complaint survey2 deficiencies▼

R-0390Significant change in resident statusOhio citation · correction confirmed 12/06/2022▼

What the surveyor found

Based on record review and family and staff interviews, the facility failed to timely notify the physician and resident's sponsor. This affected one (Resident #25) of three residents reviewed for falls at the facility. The facility census was 109.

Findings include:

Review of Resident #25's medical record revealed an admission date of 08/15/16. Diagnoses included history of cerebral vascular accident, Alzheimer's disease, dementia, history of falls, unsteady gait, and chronic kidney disease. Resident #25 required placement in the Memory Care unit.

Review of the facility's Incident Report dated 08/29/22 at 3:20 A.M. revealed Resident #25 was found lying on the ground by Caregiver (CG) #31. Resident #25 was lying supine on the floor in front of her recliner. Resident #25 was assessed for injuries and range of motion and there were no concerns identified. Resident #25 was assisted off the floor and assisted with putting on dry clothing. There was no documentation the resident's family or physician were notified of Resident #25's fall.

Interview with Resident #25's family member on 09/09/22 at 12:55 P.M. revealed the facility did not notify him Resident #25 fell until 2:00 P.M. on 08/29/22.

Interview on 09/09/22 at 8:18 A.M. with Licensed Practical Nurse (LPN) #20 revealed she was not the nurse on 08/29/22, however was the nurse on 08/30/22. LPN #20 stated she was familiar with Resident #25 and the resident's family. LPN #20 confirmed she did not timely notify Resident #25's family and physician. LPN #20 stated she notified the family and physician in the afternoon 08/29/22.

This violation substantiates Complaint Number OH00135520.

Rule

Ohio Administrative Code - residential care rules

R-0712Adequate and appropriate treatment and careOhio citation · correction confirmed 12/06/2022▼

What the surveyor found

Based on record review and staff interviews, the facility failed to provide timely care and services to Resident #25. This affected one (Resident #25) of three residents reviewed for falls at the facility. The facility census was 109.

Findings include:

Review of the Resident Care Flowsheet dated September 2022 revealed Resident #25 required one-person physical assistance for transfer, emergency response, and bed mobility. Resident #25 required complete assistance for grooming and toileting and utilized a walker.

Review of the plan of care revealed Resident #25 required safety checks every two hours for check and change.

Review of the facility's Incident Report dated 08/29/22 at 3:20 A.M. revealed Resident #25 was found lying on the ground by Caregiver (CG) #31. Resident #25 was lying supine on the floor in front of her recliner. Resident #25 was assessed for injuries and range of motion and there were no concerns identified. The vital signs were recorded as follows: blood pressure was 147/78, pulse oximetry was 69, respirations were 17, and oxygen saturation 97 percent. Resident #25 was assisted off the floor and assisted with putting on dry clothing.

Review of CG #31's undated witness statement revealed she found Resident #25 fully dressed, wet, and lying on the floor beside her chair. CG #31 apologized for checking on the resident late. CG #31 documented she was told in report by the second shift aides she had been changed and put to bed on second shift.

Interview on 09/09/22 at 8:18 A.M. with Licensed Practical Nurse (LPN) #20 revealed she was not the nurse on 08/29/22, however was the nurse on 08/30/22. LPN #20 stated she was familiar with Resident #25 and the resident's family. LPN #20 stated the son advised her that her mother had been lying on the floor from approximately 7:30 P.M. on 08/29/22 until approximately 3:30 A.M. on 08/30/22. LPN #20 stated she was not aware of the length of time Resident #25 was on the floor until the son advised her of the room camera recording. LPN #20 confirmed Resident #25 was to be checked and changed every two hours.

Interview on 09/09/22 at 8:50 A.M. with Memory Care Director (MCD) #500 stated she was aware of Resident #25's fall on 08/29/22. MCD #500 stated the four CGs assigned on second and third shift on 08/29/22 were disciplined for failing to provide check and changes on 08/29/22 at 8:00 P.M., 10:00 P.M. and 12:00 A.M. and 2:00 A.M. on 08/30/22.

Interview on 09/09/22 with the Wellness Director and the Administrator revealed they were aware of Resident #25's fall and the failure of the facility to check and change Resident #25. The Administrator confirmed the failure of the CG to check and change resulted in Resident #25 lying wet on the floor for approximately eight hours.

This violation substantiated Complaint Number OH00135520.

Rule

Ohio Administrative Code - residential care rules