Evergreen Healthcare Center
924 Charlie'S Way, Montpelier, OH 43543 · Williams County · 69 certified beds · avg 43 residents/day · certified since Apr 17, 1980
Part of chain: COMMUNICARE HEALTH (110 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 18, 2023 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 14, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 18, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 14, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (27)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 18, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jan 18, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 18, 2023 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Dec 21, 2021 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 21, 2021 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Dec 21, 2021 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Dec 21, 2021 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Dec 21, 2021 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Dec 21, 2021 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Dec 21, 2021 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (11 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 7 | 0 | D |
| 2023 | 11 | 2 | J ▲ |
| 2026 | 9 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Ohio avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.35 | 3.45 | 3.95 | top 47% in Ohio; bottom 29% in the U.S. |
| Registered Nurse hours | 0.62 | 0.60 | 0.69 | top 36% in Ohio; top 46% in the U.S. |
| Weekend total nurse staffing | 3.02 | 3.07 | 3.50 | top 44% in Ohio; bottom 32% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.42 | 0.48 | top 43% in Ohio; top 46% in the U.S. |
| Total nursing staff turnover (%) | 46.5 | 48.7 | 45.8 | top 44% in Ohio; bottom 46% in the U.S. |
| RN turnover (%) | 0.0 | 43.9 | 42.9 | top 1% in Ohio; top 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.27, RN 0.60, weekend 2.94. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Health Care Lease Facilities, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/01/2018 |
| Sxcy Holdings, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2022 |
| Sxcy MSTR Lsco, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2022 |
| C.R. Stoltz Family Investment Company INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2018 |
| C.R. Stoltz Irrevocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2018 |
| Groves, Donna | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/14/2023 |
| Gutierrez, Yvette | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/05/2021 |
| Gutierrez, Yvette | Individual | ADP of the SNF | NOT APPLICABLE | 04/05/2021 |
| Health Care Lease Facilities, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| I. Rosedale Irrevocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2018 |
| Park, Kevin | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2024 |
| Park, Kevin | Individual | ADP of the SNF | NOT APPLICABLE | 10/04/2024 |
| R.S. Wilheim Irrevocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2018 |
| Robinair Mgt Co., LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2018 |
| Robinair Mgt Co., LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/25/2025 |
| Romeo, Dominic | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2023 |
| Romeo, Dominic | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2023 |
| Ronald S Wilheim 2012 Spousal Trust | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2018 |
| Rosedale Family Investment Company, INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2018 |
| RRW, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Williams Co Hillside Country L | 7.3 mi | Bryan, OH | ★★★★☆ | 3/5 | |
| Majestic Care of Bryan | 8.2 mi | Bryan, OH | ★☆☆☆☆ | 2/5 | |
| Park View Care Center | 11.8 mi | Edgerton, OH | ★★★★★ | 4/5 | |
| Fairlawn Haven | 16.0 mi | Archbold, OH | ★★★★★ | 4/5 | |
| Pines of Dekalb | 17.4 mi | Butler, IN | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 365495.