Evergreen Health and Rehabilitation Center

380 Millwood Avenue · Winchester, VA · 22601 · 5406677010

176 certified beds For profit - Limited Liability company Chain: Hill Valley Healthcare

Why this verdict

  • Inspection record is far worse than the national median (deficiency count and severity).
  • No federal fines or payment denials in CMS’s 3-year window.

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Red flags

No standard inspection in over 2 years

The inspection record here is older than usual — conditions may have changed since.

Score breakdown

Inspection record 30% of score 37
Serious harm & abuse 20% 100
Staffing 20% 65
Federal penalties 15% 100
Trend 10% 50
Context 5% 60

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 4 of 5

Total nurse hours / resident-day3.203.48 min · 4.1 strong
RN hours / resident-day0.770.55–0.75
Weekend hours / resident-day2.94≈ weekday level
Nursing turnover / year52%median 45%
Fines (3-yr window)none

Inspection citations (55 in the current record)

  • Potential for harm · D January 10, 2024

    Allow residents to self-administer drugs if determined clinically appropriate.

    Corrected February 19, 2024 · Resident Rights

  • Potential for harm · D January 10, 2024

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected February 19, 2024 · Resident Rights

  • Potential for harm · D January 10, 2024

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    Corrected February 19, 2024 · Resident Rights

  • Potential for harm · E 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.

    Corrected February 19, 2024 · Resident Rights

  • Potential for harm · D January 10, 2024

    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 February 19, 2024 · Resident Rights

  • Potential for harm · D January 10, 2024

    Ensure each resident receives an accurate assessment.

    Corrected February 19, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D January 10, 2024

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected February 19, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D January 10, 2024

    Ensure services provided by the nursing facility meet professional standards of quality.

    Corrected February 19, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D January 10, 2024

    Provide appropriate foot care.

    Corrected February 19, 2024 · Quality of Life and Care

  • Potential for harm · D January 10, 2024

    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.

    Corrected February 19, 2024 · Quality of Life and Care

  • Potential for harm · D January 10, 2024

    Provide safe and appropriate respiratory care for a resident when needed.

    Corrected February 19, 2024 · Quality of Life and Care

  • Potential for harm · E January 10, 2024

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Corrected February 19, 2024 · Quality of Life and Care

  • Potential for harm · D January 10, 2024

    Observe each nurse aide's job performance and give regular training.

    Corrected February 19, 2024 · Nursing and Physician Services

  • Potential for harm · D January 10, 2024

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected February 19, 2024 · Pharmacy Service

  • Potential for harm · D January 10, 2024

    Ensure medication error rates are not 5 percent or greater.

    Corrected February 19, 2024 · Pharmacy Service

  • Potential for harm · E January 10, 2024

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected February 19, 2024 · Nutrition and Dietary

  • Potential for harm · E January 10, 2024

    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.

    Corrected February 19, 2024 · Administration

  • Potential for harm · D January 10, 2024

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected February 19, 2024 · Resident Assessment and Care Planning

  • Potential for harm · F January 10, 2024

    Have a plan that describes the process for conducting QAPI and QAA activities.

    Corrected February 19, 2024 · Administration

  • Potential for harm · F January 10, 2024

    Provide and implement an infection prevention and control program.

    Corrected February 19, 2024 · Infection Control

  • Potential for harm · E January 10, 2024

    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.

    Corrected February 19, 2024 · Infection Control

  • No harm found · C January 10, 2024

    Post nurse staffing information every day.

    Corrected February 19, 2024 · Nursing and Physician Services

  • Potential for harm · E April 14, 2022

    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.

    Corrected May 16, 2022 · Resident Rights

  • Potential for harm · D April 14, 2022

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    Corrected May 16, 2022 · Resident Rights

  • Potential for harm · E April 14, 2022

    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.

    Corrected May 16, 2022 · Resident Rights

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Family & resident reviews — a separate signal, never mixed into the score

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 495142 · certified since July 1, 1984. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.