Cycle 1
Health 2023-01-18 · Fire 2023-01-18
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Montpelier, OH
Evergreen Healthcare Center
2-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
924 Charlie's Way, Montpelier, OH
(419) 485-8307
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
73
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Communicare Health
Operator or chain grouping
Approved since
1980-04-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
0.95
Licensed practical nurse staffing
Aide hours / resident day
1.70
Nurse aide staffing
Weekend hours
2.85
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
92.4%
5.1 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.3%
3.1 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.2% |
26.1%
17.9 pts better
|
11.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.2% |
6.2%
3 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.4% |
25.4%
9 pts worse
|
19.6%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
11.5%
4.8 pts worse
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.0% |
7.7%
3.3 pts worse
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
6.2%
2.8 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
21.7%
3.4 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
3.7%
5.2 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
78.1%
17.6 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
12.5%
3.8 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
75.6%
6.8 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.5% |
25.1%
7.4 pts worse
|
23.9%
8.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-21 · Fire 2021-12-21
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-06-26 · Fire 2019-06-26
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-01-18
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-14
E · Potential for more than minimal harm
2023-01-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-14
F · Potential for more than minimal harm
2021-12-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-01-21
F · Potential for more than minimal harm
2021-12-21
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-01-21
F · Potential for more than minimal harm
2021-12-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-01-21
E · Potential for more than minimal harm
2021-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-01-21
E · Potential for more than minimal harm
2021-12-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-01-21
D · Potential for more than minimal harm
2021-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-21
F · Potential for more than minimal harm
2019-06-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-07-26
E · Potential for more than minimal harm
2019-06-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-26
C · Minimal harm
2019-06-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-07-26
Inspection history
Recent health citations
J · Immediate jeopardy
2023-01-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-02-14
G · Actual harm
2023-01-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-14
D · Potential for more than minimal harm
2021-12-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-01-21
D · Potential for more than minimal harm
2021-12-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-01-21
D · Potential for more than minimal harm
2021-12-21
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2022-01-21
D · Potential for more than minimal harm
2021-12-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-01-21
D · Potential for more than minimal harm
2021-12-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-21
D · Potential for more than minimal harm
2021-12-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-01-21
D · Potential for more than minimal harm
2021-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-21
Penalties and ownership
What sits behind the stars
Ownership
Sxcy Mstr Lsco, LLC
5% Or Greater Direct Ownership Interest · Organization
C.r. Stoltz Family Investment Company Inc
5% Or Greater Indirect Ownership Interest · Organization
C.r. Stoltz Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Groves, Donna
Operational/Managerial Control · Individual
Gutierrez, Yvette
Operational/Managerial Control · Individual
Health Care Lease Facilities, LLC
5% Or Greater Indirect Ownership Interest · Organization
I. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Park, Kevin
Operational/Managerial Control · Individual
R.s. Wilheim Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Robinair Mgt Co., LLC
Operational/Managerial Control · Organization
Romeo, Dominic
Operational/Managerial Control · Individual
Romeo, Dominic
Corporate Officer · Individual
Ronald S Wilheim 2012 Spousal Trust
5% Or Greater Indirect Ownership Interest · Organization
Rosedale Family Investment Company, Inc
5% Or Greater Indirect Ownership Interest · Organization
Rrw, LLC
5% Or Greater Indirect Ownership Interest · Organization
S.l. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Skilled Hc Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Stoltz, Charles
Corporate Officer · Individual
Sxcy Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wilheim Family Investment Company, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Wilheim, Ronald
Corporate Officer · Individual
Nearby options
Other facilities in reach
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#2
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1-star overall rating with 2-star inspections with $206,265 in total fines with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Park View Care Center
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5-star overall rating with 4-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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