Evergreen Retirement Community — Ohio Facility Report

Inspections on file

Deficiencies cited

Visits with none

Substandard care

Immediate jeopardy

The most recent inspection on file for Evergreen Retirement Community took place on February 5, 2026. Across the 9 inspections published by the Ohio Department of Health, surveyors cited 6 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 9 inspections listed, the state publishes the surveyor's written findings for 3; for the other 6 it publishes only the date, the type of visit and the number of deficiencies - 6 of which found none.

Facility Details

Ohio license number

#1883R

County

Hamilton

Administrator

Dave Richey

Director of nursing

Mercades Smith

Phone

(513) 948-2308

Ownership

For Profit - Limited Liability Company

Inspections

9 on file · 6 deficiencies

February 5, 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.

November 12, 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 7, 2025Licensure survey3 deficiencies▼

R-0615Fire drill requirementsOhio citation▼

What the surveyor found

Based on record review, and staff interview, the facility failed to complete and maintain documentation of fire drills as required. This had the potential to affect all 115 residents who resided in the facility.

Findings include:

Review of the documents provided upon request following entrance conference for the annual survey revealed no documented evidence of fire drills being completed February 2025 and March of 2025, resulting in lack of fire drills of the second and third shifts of the quarter.

Interview on 10/06/25 at approximately 9:30 A.M., the Director of Plant Operations, (DPO) #24 verified there was no evidence fire drills had been completed for February and March of 2025. The Administrator stated fire drills should have been completed every shift in each quarter and did not have any documentation of such.

Rule

Ohio Administrative Code - residential care rules

R-0616Disaster drill requirementsOhio citation▼

What the surveyor found

Based on record review and staff interview, the facility failed to ensure a tornado drill was completed and documented between March and July as required. This had the potential to affect all 115 residents who resided in the facility.

Findings include:

Review of the documents provided upon request following entrance conference for the annual survey revealed no documented evidence of a tornado drill being completed between March and July of the present year.

Interview on 10/06/25 at approximately 9:30 A.M. , the Director of Plant Operations, (DPO) #24 verified there was no documented evidence of a tornado drill being completed during March and July of the current year.

Interview on 10/07/25 at 3:50 P.M. the Administrator verified a tornado drill should have been conducted between March 2025 and July 2025.

Rule

Ohio Administrative Code - residential care rules

R-0627Smoking requirements, including electronic smoking device, and vapor productsOhio citation▼

What the surveyor found

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure a resident was safely smoking in a designated smoking area. The affected one Resident, ( #12 ), of one resident assessed for independent smoking. The facility total census was 115.

Findings include:

Record review of Resident #12 revealed the resident was admitted to the facility on 01/25/25/25. Diagnoses for Resident #12 history of alcohol abuse, cirrhosis of liver, and dementia.

Review of the Functional Assessment comprehensive assessment dated 07/09/25 revealed the resident had mildly impaired cognition and was independent with Activity Daily Living skills.

Review of the Resident #12 smoking risk assessment date 07/09/25 , the resident was slightly impaired for safety awareness for decision making and problem solving with a history of unsafe smoking practice.

Review of Resident #12 Service Plan dated 07/09/25 revealed the Resident #12 needed protection and supervision because he makes unsafe or inappropriate decisions.

Resident 10/07/25 at 12 :30 P.M. the Resident #12 revealed the resident smoking with no staff supervision in a courtyard near the kitchen area. The courtyard had many trees and fallen leaves. There were no cigarette receptacles or other safety equipment. There was no signage of a designated smoking area.

Observation at 1:00 P.M. revealed a smoking area at the outside front of the facility equipped with smoking safety devices.

Interview on 10/07/25 at 12:35 P.M. The Director of Wellness, (DW) verified Resident #12 was in the courtyard smoking. The DW stated the courtyard was not equipped with smoking safety devices because it was not the designated smoking area. The DW stated Resident #12 had been educated on the outside smoking area and had been previously found to have been smoking in his room. He had not been observed, since previous education, to be in the undesignated courtyard smoking.

Interview on 10/07/25 at 3:50 P.M. the Administrator verified the outside smoke area was the designated smoking area and was safely equipped for smoking. The Administrator denied knowledge Resident #12 had not been using the designated smoking area.

Review of facility policy, Resident Smoking Policy, dated 02/17/21 revealed smoking is prohibited on the entire premise, including inside residential units, all common areas and areas within thirty (30) feet of entrances, windows, doors and air-intake units, by all persons. The designated smoking area will have an appropriate rated fire extinguisher and a fire blanket. Residents will be allowed to smoke in designated smoking areas outside the community building and in accordance with the Resident Handbook and the Smoking Policy. Resident consents and agrees to abide by the Smoking Policy.

Rule

Ohio Administrative Code - residential care rules

August 19, 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.

May 23, 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.

July 29, 2024Licensure survey2 deficiencies▼

R-0559Procure, store, prepare, distribute and serve foodsOhio citation · correction confirmed 10/07/2025▼

What the surveyor found

Based on observations, staff interview, and policy review, the facility failed to store, prepare, and serve food in a manner a safe and sanitary manner. This had the potential to affect all residents who received food from the kitchen. The facility census was 86.

Findings include:

Observation of lunch tray line on 07/29/2024 from 11:17 A.M. to 11:32 A.M., revealed Cook #145 was wearing gloves doing other tasks then retrieved some Styrofoam containers. Cook #145 then used her same gloved hands to pick up and place pork chops and handfuls of waffle fries form the steam tray into the Styrofoam containers without changing gloves. Cook #145 wiped her gloved hands on her apron, then started tearing pieces of lettuce and placing them in the Styrofoam containers without changing her gloves. Cook #145 scooped prepared tuna salad on top of the lettuce garnish and used the same gloved hands to take tomatoes and hard-boiled eggs from separate bins on the refrigerated serving line and placed them in the Styrofoam containers. Chef #148 retrieved a package of turkey from the walk-in with gloves in place then removed four slices of bread from the bread bag without changing gloves. Chef #148 donned clean gloves and used a serrated knife to open the package of turkey. Chef #148 removed turkey slices from the package and placed the turkey into a metal bin on the refrigerated area of the serving table. Chef #148 proceeded to layer turkey slices, cheese slices, lettuce, and tomato slices on the bread with the same gloved hands.

Interview with Dining Services Director #142 on 07/29/2024 at 11:33 A.M. verified she had observed Cook #145 and Chef #148 touch multiple surfaces then, without changing gloves, touch food with gloved hands. The Dining Services Director #142 stated gloves were worn for one task only and changed frequently.

Review of policy titled Personal Hygiene - Hand Washing and Glove Use Standard dated 10/15/2015 revealed gloves were used for one task only and were changed as often as hands needed to be washed. Handwashing occurred prior to putting on gloves and whenever gloves were changed.

Rule

Ohio Administrative Code - residential care rules

R-0626Carbon Monoxide detector requirementOhio citation · correction confirmed 10/07/2025▼

What the surveyor found

Based on observation and staff interview, the facility failed to maintain ensure carbon monoxide detectors related to the presence of fuel-burning devices located in the boiler room and the kitchen were installed. This had the potential to affect all residents. The facility census was 86.

Findings include:

Observation on 07/29/2024 at 9:03 A.M., during the initial tour, revealed the facility had no visible carbon monoxide detectors located in a central location on each residential floor.

Observation on 07/29/2024 at 10:00 A.M., revealed the kitchen had a gas stove and there was no visible carbon monoxide detector in the kitchen.

Interview on 07/29/2024 at 2:25 P.M. with Maintenance Director #149, revealed the facility had fuel burning devices including the boiler in the basement and gas stove in the kitchen. Maintenance Director #149 stated there were no carbon monoxide detectors anywhere in the facility.

Rule

Ohio Administrative Code - residential care rules

September 17, 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.

February 3, 2023Complaint survey1 deficiency▼

R-0338Administered meds - MD ordersOhio citation▼

What the surveyor found

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure medications were administered as ordered. This affected three (#03, #07, and #13) of three residents reviewed for medication administration. The facility census was 82.

Findings include:

1. Review of the medical record of Resident #03 revealed an admission date of 08/31/11. Diagnoses included glaucoma.

Review of the service plan dated 01/27/23 revealed the resident did not take medications without staff assistance. Interventions included staff to provide total assistance with medication.

Review of the physicians orders revealed orders for Bimatoprost 0.01% eye solution, instill one drop in both eyes daily at bedtime and Netarsudil Dimesylate 0.02% eye solution, instill one drop in right eye daily at bedtime.

Review of the medication administration record (MAR) for January 2023 revealed dashes for the Bimatoprost and Netarsudil Dimesylate on 01/01/23, 01/07/23, 01/08/23, 01/09/23, 01/10/23, 01/14/23, 01/15/23, 01/19/23, 01/20/23, 01/21/23, 01/26/23, 01/28/23, 01/29/23, and 01/31/23, indicating the medication was not provided.

Review of the progress notes dated 01/01/23 through 01/31/23 revealed no documentation of refusals nor rationale for not providing medications as ordered on the aforementioned dates.

Interview on 02/01/23 at 1:00 P.M. with Resident #03 stated she was not always getting her eye drops as ordered.

2. Review of the medical record of Resident #07 revealed an admission date of 02/29/20. Diagnoses included hypertension, stroke, hypercholesterolemia, insomnia, intestinal malabsorption, hypothyroidism, constipation, cystitis, dementia without behaviors, and memory loss.

Review of the plan of care dated 10/09/22 revealed the resident did not take medications without staff assistance. Interventions included staff to provide total assistance with medication.

Review of the physician orders revealed orders for aspirin-81 milligrams (mg) by mouth daily, atorvastatin calcium-80 mg by mouth daily, cholestyramine-4 gram (gm) oral packet-use one powder by mouth twice daily, lisinopril (blood pressure medication)-5.0 mg by mouth daily, Omeprazole-20 mg by mouth daily, and Seroquel-200 mg by mouth twice daily.

Review of the January 2023 MAR revealed dashes on 01/05/23, 01/20/23, and 01/31/23 for aspirin, Lipitor, lisinopril, and Omeprazole. Further review revealed morning doses of questran and Seroquel were missed on 01/05/23, 01/20/23, 01/23/23, and 01/31/23 and evening doses were missed on 01/09/23, 01/13/23, 01/19/23, and 01/22/23.

Review of the progress notes dated 01/01/23 through 01/31/23 revealed no documentation of refusals nor rationale for not providing medications as ordered on the aforementioned dates.

Interview on 02/03/23 at 2:48 P.M. with the Director of Health Services (DHS) #300 verified dashes on the aforementioned MARs for indicated for Resident #07 on 01/05/23, 01/20/23, and 01/31/23 for aspirin, Lipitor, lisinopril, and Omeprazole; on 01/05/23, 01/20/23, 01/23/23, and 01/31/23 for the morning doses of questran and Seroquel and the evening doses were missed on 01/09/23, 01/13/23, 01/19/23, and 01/22/23.

3. Review of the medical record of Resident #13 revealed an admission date of 09/10/21 with diagnosis of idiopathic normal pressure hydrocephalus.

Review of the service plan dated 10/09/22 revealed the resident did not take medications without staff assistance. Interventions included for staff to provide total assistance with medications.

Review of the physician orders revealed orders for Atorvastatin calcium-40 mg by mouth daily, Aricept-10 mg by mouth daily, and metformin (antidiabetic) 850 mg by mouth twice daily.

Review of the January 2023 MAR revealed dashes for Lipitor on 01/05/23, 01/06/23, 01/14/23, and 01/20/23, Aricept on 01/05/23, 01/20/23, and 01/23/23. Further review revealed missing morning doses of metformin on 01/05/23, 01/20/23, and 01/23/23 and missing afternoon doses on 01/05/23, 01/06/23, and 01/20/23.

Review of the progress notes dated 01/01/23 through 01/31/23 revealed no documentation of refusals nor rationale for not providing medications as ordered on the aforementioned dates.

Interview on 02/03/23 at 2:48 P.M. with the Director of Health Services (DHS) #300 verified dashes on the aforementioned MARs indicated the medication was not administered to Resident #13: Lipitor on 01/05/23, 01/06/23, 01/14/23, and 01/20/23, Aricept on 01/05/23, 01/20/23, and 01/23/23 and metformin on 01/05/23, 01/20/23, and 01/23/23 and missing afternoon doses on 01/05/23, 01/06/23, and 01/20/23. DHS #300 verified there were no progress notes indicating rationale for not providing the medications. DHS #300 stated there had been issues with wireless connectivity, and nurses were to document on paper MARs during that time, however paper MARs were not able to be located upon surveyor request.

Review of the facility policy titled Medication Administration Records

Rule

Ohio Administrative Code - residential care rules

January 3, 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.

79.4Overall satisfaction score

85.5Ohio average

Below Ohio average

Area	This facility
Care and services	78.5
Caregivers	78.8
Environment	90.6
Facility culture	82.9
Meals and dining	75.4
Moving in	86.7
Spending time	70.6