Evergreen Health and Rehabilitation Center

380 Millwood Avenue, Winchester, VA 22601 · (540) 667-7010
For profit - Limited Liability company · 176 certified beds

Evergreen Health and Rehabilitation Center has a 2-star overall rating from Medicare, out of 5. Its last standard inspection, in January 2024, found 22 citations (the Virginia average is 14.3). It hasn't been fined in the last three years.

Medicare ratings

How to read a nursing home's star ratings

Most recent health inspection

The standard health inspection on January 10, 2024 found 22 citations. What an inspection citation means

• Have a plan that describes the process for conducting QAPI and QAA activities.January 10, 2024 · F0865 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Provide and implement an infection prevention and control program.January 10, 2024 · F0880 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.January 10, 2024 · F0623 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Provide safe, appropriate dialysis care/services for a resident who requires such services.January 10, 2024 · F0698 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.January 10, 2024 · F0812 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• 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.January 10, 2024 · F0840 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• 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.January 10, 2024 · F0887 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Allow residents to self-administer drugs if determined clinically appropriate.January 10, 2024 · F0554 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.January 10, 2024 · F0580 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.January 10, 2024 · F0582 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• 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.January 10, 2024 · F0625 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure each resident receives an accurate assessment.January 10, 2024 · F0641 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.January 10, 2024 · F0656 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure services provided by the nursing facility meet professional standards of quality.January 10, 2024 · F0658 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide appropriate foot care.January 10, 2024 · F0687 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• 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.January 10, 2024 · F0688 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide safe and appropriate respiratory care for a resident when needed.January 10, 2024 · F0695 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Observe each nurse aide's job performance and give regular training.January 10, 2024 · F0730 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.January 10, 2024 · F0755 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure medication error rates are not 5 percent or greater.January 10, 2024 · F0759 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.January 10, 2024 · F0842 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Post nurse staffing information every day.January 10, 2024 · F0732 · Level of harm: Potential for minimal harm · Residents affected: Many

Complaint inspections, last three years

Inspections after complaints found 6 citations.

• Develop and implement policies and procedures to prevent abuse, neglect, and theft.May 6, 2026 · F0607 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.May 6, 2026 · F0609 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.May 6, 2026 · F0657 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure each resident must receive and the facility must provide necessary behavioral health care and services.May 6, 2026 · F0740 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide medically-related social services to help each resident achieve the highest possible quality of life.May 6, 2026 · F0745 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.May 6, 2026 · F0842 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few

Fines and payment denials

No fines or payment denials in the last three years.

Nurse staffing

Hours of nursing care per resident per day, as the home reports them to Medicare through payroll records.

About this home