01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-09 | 9 | 2026-04-09 | 6 |
| Cycle 2 | 2023-01-18 | 11 | 2023-01-18 | 6 |
| Cycle 3 | 2021-12-21 | 7 | 2021-12-21 | 6 |
CMS CCN 3654952026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Evergreen Healthcare Center
924 Charlie'S Way · Montpelier, OH 43543 · Williams County
Certified beds69CMS provider file
Recent citation rows45current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
45 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-09 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2026-05-08 · complaint2026-04-09 · HEALTHF0791Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0805Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-09 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-05-292026-04-09 · FIREK0346Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2026-05-292026-04-09 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2026-05-292026-04-09 · FIREK0711Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2026-05-292026-04-09 · FIREK0741Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2026-05-292026-04-09 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2026-05-292023-01-18 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0600Severity J · isolated immediate jeopardy
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.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2023-02-142023-01-18 · HEALTHF0835Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Correction field: Deficient, Provider has date of correction · 2023-02-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- SXCY MSTR LSCO, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/2022
- HEALTH CARE LEASE FACILITIES, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/01/2018
- SXCY HOLDINGS, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2022
- ROMEO, DOMINICIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2023
- STOLTZ, CHARLESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2018
- WILHEIM, RONALDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2018
- ROBINAIR MGT CO., LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2018
- GROVES, DONNAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/14/2023
- GUTIERREZ, YVETTEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/05/2021
- PARK, KEVINIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2024
- ROMEO, DOMINICIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2023
- C.R. STOLTZ FAMILY INVESTMENT COMPANY INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2018
- C.R. STOLTZ IRREVOCABLE TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2018
- HEALTH CARE LEASE FACILITIES, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2022
- I. ROSEDALE IRREVOCABLE TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2018
- R.S. WILHEIM IRREVOCABLE TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2018
- ROBINAIR MGT CO., LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/25/2025
- RONALD S WILHEIM 2012 SPOUSAL TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2018
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.27per resident day
RN hours0.60per resident day
Weekend nurse hours2.94per resident day
Staff turnover46.5%CMS reported field
06 / LOCAL RECORDS
Open the Ohio ledger →Other published facilities nearby
No second facility in the same city met the directory rule.