Ashford at Sturbridge, The — Ohio Facility Report

Inspections on file

Deficiencies cited

Visits with none

Substandard care

Immediate jeopardy

The most recent inspection on file for Ashford at Sturbridge, The took place on May 13, 2026. Across the 18 inspections published by the Ohio Department of Health, surveyors cited 16 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 18 inspections listed, the state publishes the surveyor's written findings for 6; for the other 12 it publishes only the date, the type of visit and the number of deficiencies - 10 of which found none.

Facility Details

Ohio license number

#2838R

County

Franklin

Administrator

Kimberly Gibson

Director of nursing

James White

Phone

(614) 633-4811

Ownership

For Profit - Corporation

Inspections

18 on file · 16 deficiencies

May 13, 2026Complaint 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 6, 2026Complaint 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 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.

November 5, 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.

October 20, 2025Complaint survey4 deficiencies▼

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

What the surveyor found

Based on observation, interview and facility policy review, the facility failed to safely store, prepare, distribute and serve food. This had the potential to affect all residents who receive meals from the kitchen. The facility census was 89.

Findings include:

1. Observation on 10/16/25 at 10:20 A.M. of the reach in refrigerator in the kitchen near the fryer revealed the refrigerator had leaks of clear liquid on the inside and there was observed multiple cookie sheets in place to catch the leaking liquid. A clear container halfway filled with the liquid was observed in the refrigerator with floating condiment containers. A box of hot dog wieners was observed to be loosely covered in plastic bag under one of the cookie sheets that had collected the clear liquid and a gallon container of cottage cheese (no open date) with a cracked lid exposing the cottage cheese to the leaks in the walk in refrigerator.

Interview on 10/16/25 at 10:23 A.M. with the Executive Chef verified the refrigerator was leaking and confirmed a maintenance request had been put in to fix it.

2. Observation on 10/16/25 at 10:24 A.M. of the dry storage revealed a large box of sweet potatoes that appeared wrinkled and when box was touched a swarm of gnats flew out of the box. A twenty-five-pound bag of rice had a large opening on the top of the bag exposing the rice to air.

Interview on 10/16/25 at 10:24 A.M. with the Executive Chef verified the sweet potatoes were bad and they were not aware of gnats in the kitchen and the Executive Chef verified the rice should be covered.

3. Observation on 10/16/25 at 10:25 A.M. of the walk- in freezer revealed a cheesecake loosely covered by plastic undated, open bag of chicken tenders opened and exposed to the elements undated, open bag of sausage undated.

Interview on 10/16/25 at 10:27 A.M. with the Executive Chef verified items in the freezer should be labeled with open date and covered appropriately.

4. Observation of lunch service on 10/16/25 at 11:35 A.M. revealed Cook #30 walk away from tray line with gloved hands and wipe their head and face with towel and return to tray line with same gloved hands and reach for bread to make a chicken sandwich.

Interview on 10/16/25 at 11:36 A.M. with Cook #30 would not verify they did not change gloves or perform hand hygiene after wiping face and head with towel stating, I have changed my gloves twice during meal service.

Review of the facility's handwashing policy, no date, states kitchen staff must wash their hands prior to meal service, when changing tasks, after handling raw food, and when changing gloves. In addition, staff must wash their when utilizing or handling any food serving products.

Review of the facility's food handling policy, no date, states to always use a clean, appropriate serving utensil to serve food- never use your hand. If hands must be used (i.e. for sandwiches, cookies, etc.) wear clean, disposable gloves. The policy also stated use scoops to obtain bulk staples such as flour and dry cereal from bins and stated foods will be stored, prepared, and served in a safe manner.

This violation represents non-compliance investigated under Complaint Number OH00168224.

Rule

Ohio Administrative Code - residential care rules

R-0567Special diets; preparation and menuOhio citation▼

What the surveyor found

Based on medical record review and interviews the facility failed to ensure a diet was safe to consume. This affected one resident (Resident #13) with a specialized diet orders. The census was 89.

Findings include:

1. Record review of Resident #13's medical record revealed an admission date of 02/26/23. Diagnoses include chronic pain, hypertension, unspecified dementia, major depressive disorder, and migraine.

Review of Resident #13's functional assessment dated 06/05/25 revealed Resident #13 is forgetful and required safety checks every two hours due to impaired cognition and required reminders and cueing during meal. Dietary noted the resident required a mechanical soft diet and nutrition note documented type of diet as regular.

Review of the facility dietary report dated 10/08/25 revealed Resident #13 had a mechanical soft diet.

Review of the facility list of residents with specialized diet noted Resident #13 to have a specialized diet.

Review of Resident #13's progress notes dated 08/26/25 revealed Resident #13 tends to prefer a regular textured diet. Mechanical soft diet on order. Recommend diet upgrade to regular if considered safe.

Interview on 10/16/25 at 11:17 A.M. with the Executive Chef verified the facility did not have any special diets.

Interview on 10/20/25 at 11:01 A.M. with Cook #25 verified they did not have any residents with a mechanical soft diet.

Interview on 10/20/25 at 3:00 P.M. with the Director of Care verified there was not a swallow study on file for Resident #13.

This violation represents non-compliance investigated under Complaint Number OH00168224.

Rule

Ohio Administrative Code - residential care rules

R-0712Adequate and appropriate treatment and careOhio citation▼

What the surveyor found

Based on record review, interviews, facility record review, the facility failed to provide care to residents to ensure the residents had opportunities to reach their highest potential. This affected 3 residents (#25, #15 and #20) of 3 residents reviewed. The facility census was 89.

Findings include:

1. Record review of Resident #25's medical record review revealed an admission of 12/17/24. Diagnoses included heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease.

Observation on 10/20/25 at 1:50 P.M. of Resident #25 revealed Resident #25 required the use of a wheelchair.

Review of Resident #25's skilled notes for right lower extremity (RLE) wounds stated three wounds in total one on the right dorsal foot noted since 08/25/25 due to infection, and RLE distal medial wound due to venous stasis noted since 09/15/25, and RLE distal lateral wound due to venous stasis.

Review of Resident #25's medical record did not indicate a diagnosis of venous stasis.

Review of Resident #25's skilled nursing note dated 10/13/25 revealed the home care company completed Resident #25's dressing to RLE on Mondays and Thursdays.

Interview on 10/21/25 at 2:00 P.M. with the Home Care Nurse revealed the facility should be changing Resident #25's dressing as needed (PRN). The Home Care Nurse stated the dressings become saturated quickly and stated the plan of care would need to be evaluated due to first wound being in place since 08/25/25.

Interview on 10/21/25 at 3:00 P.M. with the Director of Care verified the facility did not have PRN dressing change orders in the system for Resident #25 but agreed they should be in place.

2. Review of Resident #15's medical record revealed an admission date of 04/30/25 discharge date of 08/25/25. Diagnoses included benign intracranial hypertension, hypertension, functional urinary incontinence, and Aicardi-Goutieres syndrome.

Review of Resident #15's functional assessment dated 06/05/25 revealed Resident #15's mental status as confused, and incontinent one to six times per 24 hour period. Resident #15 required total assistance with bathing and requires staff involvement with healthcare providers.

Review of Resident #15's progress notes revealed Resident #15 was admitted to hospice on 08/05/25 due to hypertensive heart disease with heart failure.

Review of Resident #15's hospice note dated 08/05/25 revealed while at the facility Resident #15's went from using a walker and able to stand to being a two-person assist noting Resident #15 had a swollen hand preventing her from being able to feed herself. Resident #15 was noted to be incontinent with bowel and bladder whereas she had stress incontinence six months ago.

Review of hospice telephone orders for Resident #15 dated 08/22/25 revealed an order for nectar thickened liquids, mechanical soft diet, feed for all meals by facility staff, family, or hospice, hoyer lift for all transfers, check and change, and monitor output for urinary retention which did not have a signature from facility staff acknowledging new orders for Resident #15.

Interview on 10/20/25 at 4:35 P.M. with the Executive Director revealed the order was not processed by facility staff and these orders were not implemented as ordered by Resident #15's hospice provider.

The facility did not have a third-party vendor order review policy in place at the time of the survey.

3. Review of Resident #20's medical record revealed an admission date of 11/16/23. Diagnoses include muscular dystrophy and sleep apnea.

Review of Resident #20's service plan dated 09/18/25 revealed Resident #20 was chair-bound and required assistance with ambulation and for bathing Resident #20 is a total assist with a bathing frequency of one to two times weekly and prefers showers and uses a bench when showering.

Review of Resident #20's bathing sheets revealed Resident #20 does not receive a shower one to two times a week and prefers male assistance with showers. Review of shower sheets revealed Resident #20 received a shower on 09/05/25, 09/19/25, 09/27/25, 10/19/25 with notes indicating refusals on 08/30/25,09/13/25 (refused- wants male aide to do shower), 09/19/25, 09/24/25, 10/04/25, 10/08/25,10/11/25 (noted as Resident prefers male assistance), 10/18/25 (stating refused prefers male aide to do showers) and shower sheets were signed by nurse but Resident #20's shower assistance preference was not reviewed.

Interview on 10/20/25 at 11:01 A.M. with Resident #20 verified his preference for male assistance with bathing.

Interview on 10/20/25 at 4:04 P.M. with the DON revealed she was not aware Resident #20 preferred male assistance with bathing stating Resident #20 sometimes agreed to a bed bath by female aides but this was not documented.

This violation represents non-compliance investigated under Complaint Number OH00168224.

Rule

Ohio Administrative Code - residential care rules

R-0717Participate in decisionsOhio citation▼

What the surveyor found

Based on interview and medical record review the facility failed to ensure the resident and responsible party were involved in the plan of care. This affected one resident #15) reviewed for care conferences and discharges. The facility census was 89.

Findings include:

1. Review of Resident #15's medical record revealed an admission date of 04/30/25 discharge date of 08/25/25. Diagnoses include benign intracranial hypertension, hypertension, functional urinary incontinence, and Aicardi-Goutieres syndrome.

Review of Resident #15's functional assessment dated 06/05/25 revealed Resident #15's mental status as confused, and incontinent one to six times in 24 hour period. Resident #15 required total assistance with bathing and required staff involvement with healthcare providers.

Review of Resident #15's progress notes revealed Resident #15 was admitted to hospice on 08/05/25 due to hypertensive heart disease with heart failure.

Review of Resident #15's hospice note dated 08/05/25 stating while at the facility Resident #15's went from using a walker and able to stand to being a two-person assist noting Resident #15 had a swollen hand preventing her from being able to feed herself. Resident #15 was noted to be incontinent with bowel and bladder whereas she had stress incontinence six months ago.

Review of messages between the business office and Resident #15's family indicated a concern over the level of care Resident #15 had been requiring.

Review of Resident #15's progress notes did not show documentation regarding completed, scheduled, or canceled care conferences regarding Resident #15's increase in level of care.

Interview with the DON on 10/20/25 at 4:01 P.M. verified she attempted to have care conferences regarding increase in Resident #15's level of care but the family was not available, but confirmed there was no documentation of the attempts.

There was not a care conference policy in place at the time of the survey.

This violation represents non-compliance investigated under Complaint Number OH00168224.

Rule

Ohio Administrative Code - residential care rules

August 21, 2025Licensure survey1 deficiency▼

R-0615Fire drill requirementsOhio citation▼

What the surveyor found

Based on review of the facility fire drill documentation, staff interview, and policy review, the facility failed to ensure residents were evacuated during at least two fire drills a year on each shift. This had the potential to affect all 92 residents.

Findings include:

Review of the facility fire drill documentation from November 2024 to July 2025 revealed no documentation to support residents were evacuated during at least two fire drills a year on each shift.

Interview on 08/21/25 at 2:51 P.M. with Executive Director #208 confirmed residents were not evacuated during at least two fire drills a year on each shift, from November 2024 to July 2025.

Review of facility policy, Fire Emergency Policy with no last revision date, revealed during fire drills the facility shall, move residents beyond the nearest set of fire doors traveling away from the fire and never cross the front of the fire area.

This violation is a recite to the annual survey completed 11/05/24.

Rule

Ohio Administrative Code - residential care rules

April 11, 2025Complaint survey · listed in Ohio's index; no findings report published1 deficiency▼

📄

1 deficiency recorded, findings not published

Ohio's inspection index lists this visit and its deficiency count, but the state publishes no findings for it.

November 29, 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.

November 5, 2024Licensure survey3 deficiencies▼

R-0098Attestation, LogOhio citation · correction confirmed 08/21/2025▼

What the surveyor found

Based on employee record review, interviews and review of policy and procedures the facility failed to ensure their Bureau of Criminal Investigation reports are submitted and received in a timely manner. This had the potential to effect all residents residing at the facility. The census was 92.

Findings include:

Review of Resident Assistant (RA) #120's employee file revealed she was hired on 06/13/24 and started working at the facility on 06/13/24.

Review of the facility's Bureau of Criminal Investigation ( BCI) log dated 11/04/23 to 11/05/24 revealed a Resident Assistant #120 was hired on 06/13/24 and her first day of work was 06/13/24. The date the criminal background check was submitted was 07/17/24. The facility received the completed criminal background report on 07/21/24. This was thirty four days after Employee #120 first day of work.

Interview with the Director of Nursing on 11/05/24 at 1:20 P.M. confirmed Resident Assistant #120 was not terminated when they did not receive her criminal background check within thirty days of her start date at the facility. RA #120 continues to work at the Assisted Living facility.

Review of facility policy titled Background Check Procedure

Rule

Ohio Administrative Code - residential care rules

R-0559Procure, store, prepare, distribute and serve foodsOhio citation · correction confirmed 08/21/2025▼

What the surveyor found

Based on observations, interviews, and facility policy review, the facility failed store and thaw food in a safe manner to prevent food contamination. This had the potential to effect 92 residents. The census was 92.

Findings include:

Observation of lunch service on 11/04/24 from 11:30 A.M. to 12:00 P.M. from the service line revealed the menu to include egg salad croissants, macaroni salad, and soup. On the serving counter and the warming shelf there were 20 already made plates of the macaroni salad and egg salad with a croissant on the side ready to be served to residents. Sever was observed to remove a plate from the warmer shelf to serve to a resident when the surveyor intervened and stopped the server. The surveyor requested to have the food items temped and it was found the temperature of the egg salad was 60 degrees Fahrenheit. Senior Executive Chef #115 verified the egg salad was too warm to serve.

Observation of two large serving pans one of egg salad and one of macaroni salad revealed the egg salad was at a temperature of 52 degrees Fahrenheit and the macaroni salad was 56 degrees Fahrenheit. The temperatures were verified by Senior Executive Chef #115.

Observation on 11/04/24 at 12:05 P.M. of a sink in the prep area revealed four large bags of frozen pork wings in the sink with hot water running over the bags.

Interview on 11/04/24 at 12:08 P.M. with the Senior Executive Chef #115 revealed she needed to thaw the wings for dinner the same day.

Review of the policy titled Food Production Management Food Handling Policy

Rule

Ohio Administrative Code - residential care rules

R-0615Fire drill requirementsOhio citation▼

What the surveyor found

Based on interviews and record review the facility failed to ensure fire drills were conducted monthly and failed to ensure there was a fire drill on each shift at least once every quarter. This had the potential to effect all residents in the facility. The census was 92.

Findings include:

Review of the maintenance fire drill documentation from 11/04/23 to 11/04/24 revealed 12 fire drills were conducted for the 12 month period. A drill was done once a month . In October 2023, December 2023, March 2024, April 2024, June 2024, July 2024 , August 2024 during the 7:00 A.M. to 3:30 P.M. shift. In May 2024, September 2024 and October 2024 a drill was conducted during the 3:00 P.M. to 11:30 P.M. shift. In February 2024 a fire drill was conducted during the 11:30 P.M. to 7:00 A.M. shift. There was no evidence a fire drill was conducted in November of 2023 and in January 2024.

Interview with Maintenance Man (MM) #105 on 11/04/24 at 1:30 P.M. verified seven fire drills were conducted on 7:00 to 3:30 P.M. shift. Three were conducted on 3:00 P.M. to 11:30 P.M. shift , and one conducted during the 11:00 P.M. to 7:30 A.M. shift in the past year. MM #105 verified there was no record of a fire drill conducted in November 2023 or January 2024.

Review of facility's Fire Safety and Evacuation Plan not dated revealed Monthly fire drills are to be completed on each shift quarterly.

Rule

Ohio Administrative Code - residential care rules

September 13, 2024Complaint survey1 deficiency▼

R-0338Administered meds - MD ordersOhio citation▼

What the surveyor found

Based on record review, facility staff interview and facility policy review, the facility failed to administer medications and monitor daily weights as ordered by the physician for two (#1 and #48) of three sampled residents. The census was 90 residents.

Findings include:

1. Clinical record review revealed Resident #1 was admitted to the facility on 10/29/22 then readmitted 07/31/24 from the hospital. Review of an assessment dated 03/15/24 revealed the resident required medication assistance and had long term memory loss. The resident had a power of attorney (POA) who was her granddaughter. The resident's diagnoses included atrial fibrillation and hypertension.

Review of physician orders revealed the resident had a physician's order dated 07/31/24 for the diuretic Lasix at 20 milligrams (mg) daily as needed based on daily weights. On 08/01/24 the resident was seen by an outside physician, was unresponsive during that visit and immediately transferred to the hospital and returned to the facility 08/05/25. On 08/09/24 the resident was assessed by an outside physician with no mention of the Lasix 20 mg as needed or daily weights ordered.

Review of the progress notes dated 08/10/24 revealed Resident #1's POA spoke to the Assistant Director of Nursing (ADON) #100 requesting clarification of the as needed Lasix order based on the resident's weight. ADON #100 asked to resident's POA to contact the resident physician for a clarification of specifically how much weight gain the resident needed for the Lasix 20 mg to be administered. On 08/14/24 the ADON #100 called the physician's office asking for the clarification. On 08/15/24 the physician ordered Lasix 20 milligrams administered as needed if the resident gained two pounds within 24 hours or five pounds within a week. The progress note dated 08/27/24 revealed Lasix was administered to the resident due to a two pound weight gain from 133 to 135.4.

Review of the Medication Administration Record (MAR) revealed no evidence the Lasix at 20 mg as needed was administered at all in the months of August and September 2024. The MAR had no recorded daily weights on 08/26/24, 09/04/24 and 09/11/24. Resident #1 had at least two pounds weight gain on 08/15/24, 08/17/24, 08/18/24, 08/21/24, 08/22/24, and 09/02/24 with no Lasix administered as ordered.

Interview with the Director of Nursing (DON) on 09/13/24 at 10:30 A.M. verified there was no recorded documentation on the MAR or progress notes of daily weights on 08/26/24, 09/04/24 and 09/11/24 for Resident #1. In addition, there was no recorded documentation on the MAR of Lasix 20 mg administered on 08/15/24, 08/17/24, 08/18/24, 08/21/24, 08/22/24, and 09/02/24 when the resident had at least a two pound weight gain within 24 hours. The DON revealed the clarification for the Lasix 20 mg physician's order as needed should have happened timely when the resident returned from the hospital on 08/05/24, not on 08/15/24.

2. Clinical record review revealed Resident #48 was admitted to the facility on 08/08/24 with diagnoses including heart disease and history of stroke.

Review of the physician orders dated 09/06/24 revealed the diuretic Lasix at 20 mg daily every evening, to monitor daily weights, and to notify the physician if the resident's weigh increased two pounds within 24 hours or five pounds within a week.

Review of the MAR for September 2024 revealed Resident #48 had no weights recorded for 09/07/24, 09/09/24, 09/10/24, and 09/11/24.

Interview with the DON on 09/13/24 at 10:30 A.M. verified there were no weights recorded for 09/07/24, 09/09/24, 09/10/24, and 09/11/24 on the MAR or in the progress notes for Resident #48.

Review of the policy titled Medications dated 03/2020 revealed all orders were obtained from a physician before administering medications. The nurse or designee referred to the MAR to obtain the correct medication, time, dosage, and route of administration as ordered by the physician. Each dose administered was properly recorded on the MAR by the nurse or designee. The DON controlled and managed all residents' medication program.

This licensure violation substantiated allegations contained in Complaint Control OH00157263.

Rule

Ohio Administrative Code - residential care rules

August 15, 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.

May 16, 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.

December 28, 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.

September 14, 2023Complaint survey · listed in Ohio's index; no findings report published1 deficiency▼

📄

1 deficiency recorded, findings not published

Ohio's inspection index lists this visit and its deficiency count, but the state publishes no findings for it.

April 25, 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 23, 2023Complaint survey1 deficiency▼

R-0733Use personal clothing and possessionsOhio citation · correction confirmed 05/11/2023▼

What the surveyor found

Based on medical record review, staff and family interview, review of the admission contract, and review of a facility email correspondence, the facility failed to ensure residents were permitted to have personal possessions related to the use of monitoring cameras in their rooms. This affected one (#92) of three residents reviewed for reasonable use of personal belongings. The facility census was 94.

Findings include:

Review of the medical record for Resident #92 revealed an initial admission date of 02/26/23 with diagnoses including dementia, hypertension, chronic pain, major depressive disorder, migraine and headache.

Review of the facility resident agreement section six paragraph J revealed the community prohibits the use of any video or audio recording of its campus, property, staff and residents. The privacy of employees and residents must be maintained and thereby videotaping and audio recording is prohibited. No cameras, including cell phone cameras, recorders, or other types of recording devices are permitted to be installed by resident or resident family or are permitted to be used on the community premises. Violators will be subject to eviction for failure to comply with the community's rules and regulations.

Review of Resident #92's resident agreement, dated 02/07/23, revealed the resident's family member crossed out section six paragraph J with the word omit. The family member placed their initials next to the word omit.

Interview on 03/23/23 at 11:31 A.M., with Resident #92's family member revealed the Executive Director (ED) informed the family member the monitoring cameras in the resident's apartment must be removed within 24 hours or the resident would be evicted within the 24 hours following. The family member revealed the monitoring cameras were in place prior to the resident transferring to the facility. The family member revealed on Resident #92's admission agreement, she crossed out and initialed the portion of no cameras in apartments were prohibited and Admissions Coordinator #157 signed the contract.

Interview on 03/23/23 at 11:52 A.M., with the ED revealed she was unaware of Resident #92's family placing monitoring cameras in the resident's apartment. She revealed she did not tell the resident's daughter Resident #92 that the resident would be discharged in 24 hours but if the monitoring cameras remained it would result in an eviction. She revealed she had emails from the regional vice president to move forward with the eviction if the monitoring cameras were not removed from the resident's apartment.

Review of the email correspondence between the ED and Regional Vice President (RVP) #158 dated 03/21/23 revealed RVP #158 confirmed the facility prohibited monitoring cameras in the facility. RVP #158 also included the paragraph from the admission agreement indicating violators of the video/audio recording will be subject to eviction for failure to comply with the community rules and regulations.

This violation represents non-compliance investigated under Master Complaint Number OH00141419.

Rule

Ohio Administrative Code - residential care rules

March 7, 2023Licensure survey4 deficiencies▼

R-0098Attestation, LogOhio citation · correction confirmed 06/08/2023▼

What the surveyor found

Based on review of personnel files and staff interview, the facility staff failed to maintain a log for each hired employee of the required information from the Bureau of Criminal Investigation (BCI) screenings. The finding potentially affected all 94 residents. Facility census was 94.

Findings include:

Review of five personnel files revealed evidence of BCI screening for each employee in sealed envelops. However, there was no evidence the staff maintained a BCI log for all hired staff with the required information.

Interview with the Administrator on 03/07/23 at 2:30 P.M. verified there was no BCI log with the required information.

Rule

Ohio Administrative Code - residential care rules

R-0614Notify director when normal business interruption due to emergency/disasterOhio citation · correction confirmed 05/11/2023▼

What the surveyor found

Based on reviewed of the fire drill documentation and staff interview, the facility staff failed to conduct the required on each shift every three months. This had the potential to affect all 94 residents residing in the facility. Facility census was 94.

Findings include:

Review of the fire drills documentation the past year revealed there was no first shift fire drill conducted during the third quarter of 2022. On the evening and night shifts, there was no fire drill conducted during the first, second and third quarters of 2022.

Interview on 03/07/23 at 3:15 P.M. with Regional Maintenance Staff (RMS) #50 verified there was no first shift fire drill conducted during the third quarter of 2022. RMS #50 verified on the evening and night shifts, there was no fire drill conducted during the first, second and third quarters of 2022.

Rule

Ohio Administrative Code - residential care rules

R-0627Smoking requirements, including electronic smoking device, and vapor productsOhio citation · correction confirmed 05/11/2023▼

What the surveyor found

Based on observation and staff interviews, the facility failed to post No Smoking signs on the resident doors where oxygen was in used. This affected two (#7 and #2) out of two residents sampled for oxygen usage. Facility census was 94.

Findings include:

Observations on 03/07/23 at 11:26 A.M. revealed Resident #7 had an oxygen concentrator tank in her room next to her bed with no sign on the door related to No Smoking. Further observations revealed Resident #2 had two oxygen tanks in her room with no sign posted on the door related to No Smoking. Both residents lived on the second floor.

Interview with Aide #70 on 03/07/23 at 11:30 A.M. verified the oxygen stored in the rooms for Residents #2 and #7 with no posted signs on the doors related to No Smoking.

Interview with the Director of Nursing on 03/07/23 at 11:40 A.M. verified the lack of signs for Residents #2 and #7 and stated there was no policy related to posting of No Smoking signs on rooms where oxygen was used or stored. The facility had a no smoking policy on campus.

Rule

Ohio Administrative Code - residential care rules

R-0680Maintain building and groundsOhio citation · correction confirmed 05/11/2023▼

What the surveyor found

Based on observations and staff interviews, the facility failed to maintain the laundry areas in a clean and safe manner. The finding potentially affected all 94 residents. Facility census was 94.

Findings include:

Observations completed on 03/07/23 at 10:50 A.M. of the first floor commercial dryers used by the staff for resident laundry revealed the lint traps on the two dryers had an inch thick build up of lint. Interview with the Administrator at that time verified the inch thick build up of lint on the two dryer traps.

Observations completed on 03/07/23 at 11:00 A.M. of the first floor washing machine used by both residents and staff revealed the rubber gasket of one of the front loading washing machines had a heavy black slime all around it that wiped off. The washing machine had an unpleasant odor when the door was opened.

Interview with the Administrator on 03/07/23 at 11:00 A.M. verified the odor and heavy black slime around the rubber gasket of the first floor front loading washing machine. The Administrator verified there was no documentation of when the dryer lint traps or washing machines were last cleaned.

Rule

Ohio Administrative Code - residential care rules

February 13, 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.

Resident Satisfaction

2025-2026 survey

Ohio interviews residents directly and publishes the results by area. Scores run from 0 to 100.

78.5Overall satisfaction score

85.5Ohio average

Below Ohio average

Area	This facility
Care and services	94.3
Caregivers	73.1
Environment	94.6
Facility culture	74.3
Meals and dining	75.5
Moving in	57.9
Spending time	76.2