Evergreen Health and Rehabilitation Center
380 Millwood Avenue, Winchester, VA 22601 · Winchester City County · (540) 667-7010
176 certified beds, about 172 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1984
Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495142 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on January 10, 2024, inspectors cited 22 health deficiencies (the Virginia average is 14.3, the national average 9.2).
None of its 61 health citations since April 2019 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.16 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.81 of those hours.
49.7% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Hill Valley Healthcare, an affiliated group of 43 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1604/19
1704/22
2201/24
605/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 61 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
41D
15E
3F
Potential for minimal harm
0A
0B
2C
May 6, 2026Complaint inspection · 6 citations
- D Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to implement its policy to report an allegation of abuse for one of eight residents in the survey sample, Resident #8.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to report an allegation of abuse for one of eight residents in the survey sample, Resident #8.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of eight residents in the survey sample, Resident #6.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide behavioral health services for one of eight residents in the survey sample, Resident #6.
- D Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of eight residents in the survey sample, Resident #6.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of eight residents in the survey sample, Resident #2.
January 10, 2024Standard inspection · 22 citations
- F Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on staff interview and facility document review it was determined that the facility staff failed to evidence a continuous Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all Residents within the facility during quarter two (Q2) to quarter four (Q4) of 2022.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an effective infection control program for two of 42 residents in the survey sample, Residents #124 and #122, and failed to maintain the infection control tracking logs.
- E Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that written RP (responsible party) and ombudsman notification was provided, for four of 42 residents in the survey sample who were transferred to the hospital, Residents #96, Resident #99, Resident #9 and Resident #125.
- E Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident and staff interview, resident interview, clinical record review, and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 42 residents in the survey sample, Resident #99.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain a sanitary environment in one of one kitchen.
- E Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for one of one dialysis residents in the survey sample, Resident #99.
- E Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to implement the COVID-19 vaccination policy for four of five resident immunization reviews, Residents #95, #10, #98, and #12.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to assess one of 42 residents in the survey sample for safe self-administration of medications, Resident #134.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interview and clinical record review, it was determined the facility staff failed to notify the physician or nurse practitioner, when medications were not available for administration for two of 42 residents in the survey sample, Resident #110 and #95.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to provide notice of Medicare non-coverage for one of three beneficiary protection notification resident reviews, Resident #413.
- D 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.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when three out of 42 residents in the survey sample were transferred to the hospital, Residents #96, Resident #99, and Resident #125.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accurately code an MDS (minimum data set) assessment for one of 42 residents in the survey sample, Resident #75.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, resident interview, staff interviews, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 42 residents in the survey sample, Resident #99.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications, for one of 42 residents in the survey sample, Residents #110.
- D Provide appropriate foot care.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide foot care to one of 42 residents in the survey sample, Resident #7.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for hand contractures for one of 42 residents in the survey sample, Resident #2.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, resident interviews, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for three of 42 residents, Resident #134, #398, and #21.
- D Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview, facility document review and employee record review, the facility staff failed to provide mandatory training for five of five CNA (certified nursing assistant) records reviewed, CNAs #8, #9, #10, #11, and #12.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide pharmacy services for one of 42 residents in the survey sample, Resident #95.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to administer medications at an error rate less than 5% to one of five residents in the medication administration observation, Resident #140. This resulted in a total of two medication errors in a total of 36 administration opportunities, and a calculated medication error rate of 5.56%.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 42 residents in the survey sample, Resident #75.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to meet the requirements for the daily staff posting on two of three days of the survey, 1/8/24 and 1/9/24.
April 14, 2022Standard inspection · 17 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens.
- E Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to evidence discussion of an advance directive for six of 45 residents in the survey sample, Resident #110, #47, #50, #111, #61 and #58
- E Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 45 residents in the survey sample were transferred to the hospital; Residents #94, #59, #124, #95 and #10.
- E Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident or RP (responsible party) and ombudsman upon transfer to the hospital for five out of 45 residents in the survey sample; Residents #94, #59, #124, #95 and #10.
- E 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.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed hold was provided to four out of 45 residents in the survey sample who were transferred to the hospital; Residents #94, #59, #124 and #95.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for 3 of 45 residents in the survey sample; Residents #57, #16, and #54.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for five of five CNA record reviews. The facility staff failed to complete an annual performance review for CNA #2, CNA #3, CNA #4, CNA #5 and CNA #6.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) to one of three beneficiary protection notification resident reviews, Resident #106. Resident #106's (R106) last covered day of Medicare part A services was 11/7/21. The facility staff failed to provide the SNFABN to Resident #106 (and/or the resident's representative).
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 2 of 45 residents in the survey sample, Resident #31 and Resident #110.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for one of 45 residents in the survey sample, #57.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to ensure 2 of 45 residents were free of safety hazards, Resident #56 and Resident #36. Resident #56 and #36's bed rails were observed to be visibly loose creating a potential safety hazard.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record reviews and facility document review it was determined that the facility staff failed to administer oxygen as ordered to two of 45 residents in the survey sample, Resident #93 and #117.
- D Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record reviews and facility document review it was determined that the facility staff failed to assess 2 of 45 residents in the survey sample for the use of bed rails, Resident #93 and #54.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record reviews, facility document review and staff interview it was determined that the facility failed to maintain a complete and accurate clinical record for one of 45 residents in the survey sample, Resident #31 (R31).
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow infection control practices for one of six residents in the medication administration observation, Resident #16.
- D Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure CNAs (certified nursing aides) completed required annual in-service training for two of five CNA record reviews. The facility staff failed to ensure CNA #4 and CNA #6 completed annual dementia training.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post complete nurse staffing information. Nurse staffing information posted on 4/13/22 failed to document the facility name and failed to separate the actual hours and total number of RNs (registered nurses) and LPNs (licensed practical nurses).
April 25, 2019Standard inspection · 16 citations
- E Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility documentation and clinical review, it was determined that the facility staff failed to provide respiratory care services consistent with professional standards of practice, and the comprehensive person-centered care plan for three of 47 residents in the survey sample; Residents #117, #32 and #58. 1. The facility staff failed to ensure a physician's order was in place prior to the administration of oxygen to Resident #117. 2. The facility staff failed to store a nebulizer mask and incentive spirometer (1) in a sanitary manner. 3. The facility staff failed to administer oxygen to Resident #58 per the physician prescribed rate of two liters per minute.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview and employee record review it was determined that the facility staff failed to ensure that five of 5 CNA records reviewed received the required 12 hours of annual training's, to include the required training's for Abuse and Dementia Care.
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure that two of five residents in the medication administration observation (Residents #75 and #47) were free of a medication error rate of five percent or less. There were 3 errors out of 25 opportunities and the medication error rate was 12%. 1. The facility staff failed to obtain Resident #75's blood pressure prior to administering a blood pressure medication. The determination as to administer or hold the medication was dependent on the resident's blood pressure, per the physician's order. 2. The facility staff failed to prepare Resident #47's medications appropriately during medication administration observation by crushing iron enteric-coated tablet and isosorbide mononitrate extended release tablet.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to label and store medications according to professional standards in three of seven facility medication carts; (the wing one back hall medication cart, wing two front hall medication cart and wing four medication cart), and in one of four medication refrigerators (the wing 100 medication refrigerator). The facility staff failed to label medication in the wing one back hall medication cart and wing four-medication cart and failed to discard expired medication in the wing one back hall medication cart, wing one medication refrigerator and wing two front hall medication cart.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a dignified dining experience for two of 47 residents in the survey sample, Residents #53 and #97. 1. The facility staff failed to serve lunch to Resident #94 in a dignified manner. Another resident seated at the same table as Resident #53 was served a meal and Resident #53 was not served a meal until 27 minutes later. 2. The facility staff stood next to Resident # 97 while assisting them with eating during lunch.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to notify the physician of a possible need to alter treatment for one of 47 residents in the survey sample, Resident #81. The facility staff failed to notify the physician when Crestor (Rosuvastin) (1) 10 MG (milligram) was not available for administration to Resident #81 on 01/04/19, 01/07/19, and 01/08/19.
- D Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide the receiving facility, the required documentation upon transfer for three of 47 residents in the survey sample, Residents # 15, # 73, and #114. 1. The facility staff failed to provide the receiving hospital the comprehensive care plan goals upon Resident # 15's transfer to the hospital on 1/1/19 and 1/13/19. 2. The facility staff failed to provide the required documentation to the hospital for a facility initiated hospital transfer of Resident #73 on 2/27/19. 3. The facility staff failed to evidence the comprehensive care plan goals were provided to the receiving facility when Resident #114 was transferred to the hospital on 3/14/19 and 319/19.
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide written notification of transfer to the resident and/or resident representative and failed to notify the ombudsman of transfers to the hospital for three of 47 residents in the survey sample, Residents #15, #73 and #114. 1. The facility staff failed to provide written documentation to the resident and/or resident representative for the transfer of Resident #15 to the hospital on 1/13/19. 2. The facility staff failed to provide Resident #73 or the resident's representative (RR) with written documentation of a facility initiated transfer dated 2/27/19. 3. [...]
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 47 residents in the survey sample, Resident #58. The facility staff failed to attempt the BIMS (Brief Interview for Mental Status) interview for Resident #58's quarterly MDS assessment with an ARD (assessment reference date) of 3/4/19.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, staff interview, resident interview, facility documentation review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for two of 47 residents in the survey sample (Resident #21, #32). 1. The facility staff failed to develop a comprehensive care plan for Resident #21's indwelling urinary catheter (1). 2. The facility staff failed to implement the comprehensive care plan for non-pharmacological interventions prior to the administration of as needed pain medication to Resident #32.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 47 residents in the survey sample; Resident #114 and Resident #58. 1. The facility staff failed to review and revise Resident #114's comprehensive care plan to address the administration of the antipsychotic medication Seroquel. 2. The facility staff failed to review and revise Resident #58's care plan for oxygen administration.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on staff interview, resident interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure pain management services, consistent with professional standards of practice, and the comprehensive person-centered care plan for two of 47 residents in the survey sample, Residents #108 and #32. 1. The facility staff failed to clarify Resident #108's medication orders for two as needed pain medications to determine when each medication should be administered to the resident based on pain level parameters to ensure effective consistent pain management. 2. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication to Resident #32
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure medications were available for one of 47 residents in the survey sample, Resident #81. The facility staff failed to ensure the physician prescribed medication Crestor Tablet 10 MG (Rosuvastatin calcium) (1) was available for administration to Resident #81 as ordered.
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure one of 47 residents in the survey sample, was free of unnecessary psychotropic medications; Resident #114. Resident #114 was administered Seroquel (1), an antipsychotic medication without adequate indications and diagnosis for the administration of the medication.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in accordance with professional standards for food service safety. The facility staff failed to ensure the margarine in the refrigerator was not open to air.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for two of ten residents in the survey sample, Residents #102 and #105. 1. The facility staff failed to document non-pharmacological interventions that were provided to Resident #102 prior to as needed acetaminophen administration on 5/30/19 and failed to accurately document Resident #102's pain level on that same date. 2. The facility staff failed to document accurately Resident #105's pain level on 6/3/19.
Fire safety inspections
11 fire safety citations on file: 1 on January 10, 2024, 10 on April 25, 2019.
Every fire safety citation11 citations
- D Install corridor and hallway doors that block smoke.
- E 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.
- E To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E Have proper medical gas storage and administration areas.
- D Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- D Install corridor and hallway doors that block smoke.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D Provide a written emergency evacuation plan.
- D Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
- D Have generator or other power source capable of supplying service within 10 seconds.
- D Ensure proper usage of power strips and extension cords.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Virginia | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.16 | 3.76 | 3.86 |
| Registered nurses | 0.81 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.93 | 3.29 | 3.42 |
| Nurse aides | 1.71 | ||
| Licensed practical nurses | 0.63 | ||
| Nursing staff turnover (share who left in a year) | 49.7% | 48.1% | 45.8% |
| Registered nurse turnover | 54.8% | 48.2% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.51 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.25 on weekdays and 2.93 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 15.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.10 in April to June 2025 to 3.16 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.16 | 0.81 | 3.25 | 2.93 | 15.6% | 0 of 90 | 172 |
| Oct to Dec 2025 | 3.20 | 0.77 | 3.31 | 2.94 | 17.8% | 0 of 92 | 171 |
| Jul to Sep 2025 | 3.29 | 0.77 | 3.42 | 2.95 | 15.7% | 0 of 92 | 168 |
| Apr to Jun 2025 | 3.10 | 0.66 | 3.18 | 2.91 | 19.4% | 0 of 91 | 168 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Virginia, Jan to Mar 2026 | 3.58 | 0.56 | 3.76 | 3.12 | 5.7% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for Virginia
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Virginia, all employers | |||
| CNAs (nursing assistants) | $20.77 | $17.80 to $22.56 | 40,580 |
| LPNs and LVNs | $31.21 | $28.66 to $35.84 | 15,550 |
| Registered nurses | $45.00 | $38.51 to $49.53 | 77,490 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Virginia | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.0 | 14.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.9 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.0 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.8 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.6 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.2 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.6 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.6 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.6 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.5 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.0 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.5 | 1.8 |
Owners and operators
Legal business name: EVERGREEN SNF OPERATIONS LLC. CMS links this home to Hill Valley Healthcare, a group of 43 nursing homes averaging 1.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Evergreen SNF Operations Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 07/01/2021 |
| Copper VA Trust | 5% or greater indirect ownership interest | Organization | 07/01/2021 | |
| Evergreen Noble Parentco LLC | 5% or greater indirect ownership interest | Organization | 07/01/2021 | |
| Gold VA Trust | 5% or greater indirect ownership interest | Organization | 07/01/2021 | |
| Hvh Evergreen Operations Holdings LLC | 5% or greater indirect ownership interest | Organization | 07/01/2021 | |
| Silver VA Trust | 5% or greater indirect ownership interest | Organization | 07/01/2021 | |
| Meisner, Robert | 5% or greater indirect ownership interest | Individual | 07/01/2021 | |
| Ringstaff, Ramona | W-2 managing employee | Individual | 07/01/2021 | |
| Idels, Shimon | Corporate officer | Individual | 01/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 14 problems in this area, most recently on May 6, 2026: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 14 problems in this area, most recently on January 10, 2024: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 11 problems in this area, most recently on May 6, 2026: "Ensure each resident must receive and the facility must provide necessary behavioral health care and services."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 6 problems in this area, most recently on January 10, 2024: "Observe each nurse aide's job performance and give regular training."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.93 hours per resident per day, below the Virginia average of 3.29.
Other nursing homes nearby
- Shenandoah Valley Westminster Canterbury Winchester, 2.3 mi · 4 of 5 stars · 22 citations
- Winchester Health & Rehabilitation Winchester, 2.4 mi · 1 of 5 stars · 71 citations
- The Village at Orchard Ridge Winchester, 3.3 mi · 5 of 5 stars · 4 citations
- Rose Hill Health and Rehab Berryville, 10 mi · 1 of 5 stars · 75 citations
- Heritage Hall Front Royal Front Royal, 15.6 mi · 5 of 5 stars · 6 citations
- Lynn Care Center Front Royal, 16.7 mi · 2 of 5 stars · 54 citations
- Willow Tree Healthcare Center Charles Town, 18.3 mi · 3 of 5 stars · 54 citations
- Shenandoah Center Charles Town, 19 mi · 2 of 5 stars · 53 citations
Virginia contacts for a concern about a nursing home
These are the official offices in Virginia. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Virginia Department of Health, Office of Licensure and Certification, Division of Long-Term Care Services, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Virginia Office of the State Long-Term Care Ombudsman, 800-552-5019. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: VDH Nursing Home and ICF/IID Inspections and Surveys, where Virginia publishes its own records on licensed homes.
Common questions
- What is Evergreen Health and Rehabilitation Center's Medicare star rating?
- CMS rates Evergreen Health and Rehabilitation Center 2 out of 5 stars overall, with 2 for health inspections, 2 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Evergreen Health and Rehabilitation Center get at its last inspection?
- 22 health deficiencies at the standard inspection on January 10, 2024. The Virginia average is 14.3.
- Has Evergreen Health and Rehabilitation Center been fined?
- CMS lists no fines in the last three years.
- Does Evergreen Health and Rehabilitation Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Evergreen Health and Rehabilitation Center?
- CMS lists 9 owners and managers, and links the home to Hill Valley Healthcare. Legal business name: EVERGREEN SNF OPERATIONS LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.