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Nursing HomeMedicaid Investigative

Evergreen Healthcare Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

924 Charlie's Way, Montpelier, OH 4354373 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 53 Google reviews

5
4
3
2
1

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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (2/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (11 vs median 8.0)

Bottom 25% in OH · Below recommended RN staffing · Below chain average · No penalties on record · Abuse citation

Source: Medicare data

What this means for your family

While the facility is frequently praised for its clean environment and compassionate staff, the recurring reports of neglect and medication errors are serious red flags. When touring, ask specifically about the nurse-to-patient ratio on weekends and request a detailed plan for how they monitor and document daily hygiene and medication adherence.

Google Reviews

Google Reviews

53 reviews on Google
Evergreen Healthcare Center receives highly polarized reviews, with many recent positive reports praising the compassionate nursing staff and effective therapy teams. However, significant concerns persist regarding basic hygiene, medication management, and responsiveness to medical needs, particularly during off-hours or weekends. Families should be aware that while many find the environment warm and welcoming, others have reported serious lapses in care and communication.

Quality Themes

Tap a score for details
Food6.0Staff7.0Clean8.0Activities9.0Meds2.0MemoryN/AComms4.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Effective physical therapy services
  • Clean and home-like facility environment
  • Helpful and organized admissions process

Concerns

  • Neglect of basic hygiene and personal care (mentioned by 3 reviewers)
  • Inadequate medication management and monitoring (mentioned by 2 reviewers)
  • Understaffing leading to slow response times (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2342.0'17(2)3.45.0'19(3)4.11.3'23(3)4.94.0'25(24)4.3'26(11)

Distribution · 80 analyzed

5
59
4
3
3
2
2
2
1
14

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the current staffing levels, what specific protocols do you have in place to ensure that residents receive timely assistance with daily hygiene and personal care needs?
  • 2Could you walk me through your current medication management process and explain what steps are taken to ensure accuracy and consistent monitoring for residents?
  • 3I noticed the facility has had some recent state violations; what specific improvements or changes in policy have you implemented over the last year to address these findings?
  • 4Many families have praised your physical therapy team; how do you integrate these therapy services into the daily routine of residents who need extra support?
  • 5What is your standard procedure for communicating updates or health changes to family members, and how do you ensure that communication remains consistent?
  • 6Since the facility is home to 73 residents, what kind of structured social activities or programs do you offer to keep everyone engaged and connected throughout the week?

Personalized based on this facility's data


Key Review Excerpts

She was treated extremely well & our family members received kind compassion at our end days with mom. I pray the staff is respected & rewarded by administration because they were literally earth angels.

Long-term resident's family · 2026★★★★★

Many times I came into the facility and my mom was in the TV room in a recliner and a staff member was sitting in the recliner with her, it really felt like a home

Long-term resident's family · 2025★★★★★

They don't follow through. They don't make sure meds are taken. They let patients sit in their own filth. There is no sense of urgency, compassion, empathy or understanding.

Family member · 2025☆☆☆☆
Source: 53 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.56hrs
74%
Registered nurses for medical care
Total Nursing
3.23hrs
79%
All nurses + aides combined
Staff Turnover
45%
Lower is better (< 30% = good)
RN Turnover
0%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

12

measures

Worse Than Avg

3

measures

Mixed Results

2

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility7.4%
Better than Avg
Here
7.4%
US
12.1%
OH
28.2%
Williams
8.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility35.2%
Worse than Avg
Here
35.2%
US
19.5%
OH
25.4%
Williams
20.6%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility4.4%
Better than Avg
Here
4.4%
US
14.4%
OH
5.8%
Williams
18.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility6.0%
Better than Avg
Here
6.0%
US
15.3%
OH
6.9%
Williams
14.5%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility17.1%
Worse than Avg
Here
17.1%
US
15.5%
OH
9.4%
Williams
13.7%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.3%
Better than Avg
Here
99.3%
US
93.4%
OH
92.6%
Williams
95.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility96.7%
Better than Avg
Here
96.7%
US
81.8%
OH
78.4%
Williams
86.7%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility82.4%
Better than Avg
Here
82.4%
US
79.8%
OH
75.6%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
OH
1.2%
Williams
3.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

12deficiencies
Above state avg (10.1)
1 complaint-triggered

Evergreen Healthcare Center shows concerning patterns with 33 deficiencies across three surveys, including serious issues with abuse protection and medication management. The facility has struggled with fire safety systems, infection control, and resident rights across multiple years. While all deficiencies show correction dates, the recurring problems with medication errors, safety protocols, and resident protection suggest ongoing operational challenges that families should carefully consider.

Apr 9, 2026Complaint
1
0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Jan 18, 2023Routine
17
0600Immediate jeopardy · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0222Potential for harm · WidespreadCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0741Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0835Potential for harm · IsolatedCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Dec 21, 2021Routine
13
0004Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

0006Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

0351Potential for harm · WidespreadCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0374Potential for harm · PatternCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

0655Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Jun 26, 2019Routine
3
0321Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0039Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Evergreen Healthcare Center

Organization Type

for profit

Chain Affiliation

Chain Name

Communicare Health

Chain Size

121 facilities nationwide

Chain avg rating: 2.8/5 · Rank 73 of 121

Ownership & Management

Owners

Sxcy Mstr Lsco, LLC

Owner · Organization

100%

Health Care Lease Facilities, LLC

Owner (parent company) · Organization

Sxcy Holdings, LLC

Owner (parent company) · Organization

Key personnel

Romeo, DominicOfficer / DirectorStoltz, CharlesOfficer / DirectorWilheim, RonaldOfficer / DirectorRobinair Mgt Co., LLCManagerGroves, DonnaManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

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Safer Alternatives Nearby

Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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