EVERGREEN HEALTH AND REHABILITATION CENTER, WINCHESTER

CCN 495142 · EVERGREEN SNF OPERATIONS LLC · Winchester City · VA · For profit - Limited Liability company · HILL VALLEY HEALTHCARE chain · 176 certified beds


Certified for Medicare and Medicaid since 1984-07-01, EVERGREEN HEALTH AND REHABILITATION CENTER, WINCHESTER is a 176-bed nursing home in WINCHESTER, Virginia, averaging 172.3 residents a day.

Has EVERGREEN HEALTH AND REHABILITATION CENTER, WINCHESTER been cited for violations?

CMS lists 61 health-inspection deficiencies for EVERGREEN HEALTH AND REHABILITATION CENTER, WINCHESTER since 2019-04-25, 28 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is F; the most recent health inspection was 2026-05-06.

Survey dateTagDeficiencySeverity
2026-05-06F0607, F0609, F0657, F0740, F0745, F0842Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Ensure each resident must receive and the facility must provide necessary behavioral health care and services. / Provide medically-related social services to help each resident achieve the highest possible quality of life. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D
2024-01-10F0865, F0880Have a plan that describes the process for conducting QAPI and QAA activities. / Provide and implement an infection prevention and control program.F
2024-01-10F0623, F0698, F0812, F0840, F0887Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / 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. / 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.E
2024-01-10F0554, F0580, F0582, F0625, F0641, F0656, F0658, F0687, F0688, F0695, F0730, F0755, F0759, F0842Allow residents to self-administer drugs if determined clinically appropriate. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / 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. / Ensure each resident receives an accurate assessment. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure services provided by the nursing facility meet professional standards of quality. / Provide appropriate foot care. / 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. / Provide safe and appropriate respiratory care for a resident when needed. / Observe each nurse aide's job performance and give regular training. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure medication error rates are not 5 percent or greater. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D
2024-01-10F0732Post nurse staffing information every day.C
2022-04-14F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2022-04-14F0578, F0622, F0623, F0625, F0657, F0730Honor 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. / 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. / Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / 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. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Observe each nurse aide's job performance and give regular training.E
2022-04-14F0582, F0641, F0656, F0689, F0695, F0700, F0842, F0880, F0947Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / Ensure each resident receives an accurate assessment. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide safe and appropriate respiratory care for a resident when needed. / 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. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Provide and implement an infection prevention and control program. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.D
2022-04-14F0732Post nurse staffing information every day.C
2019-04-25F0695, F0730, F0759, F0761Provide safe and appropriate respiratory care for a resident when needed. / Observe each nurse aide's job performance and give regular training. / Ensure medication error rates are not 5 percent or greater. / 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.E
2019-04-25F0550, F0580, F0622, F0623, F0641, F0656, F0657, F0697, F0755, F0758, F0812, F0842Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / 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. / Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / Ensure each resident receives an accurate assessment. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide safe, appropriate pain management for a resident who requires such services. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D

How is EVERGREEN HEALTH AND REHABILITATION CENTER, WINCHESTER staffed relative to the VA average?

MeasureThis facilityVA average
Total nurse staffing hours per resident per day3.156843.75779
Total nursing staff turnover (%)49.748.1
Average number of residents per day172.399.5

Who owns EVERGREEN HEALTH AND REHABILITATION CENTER, WINCHESTER, and what chain is it in?

EVERGREEN HEALTH AND REHABILITATION CENTER, WINCHESTER is registered with CMS as For profit - Limited Liability company, operates under the legal business name EVERGREEN SNF OPERATIONS LLC and belongs to the HILL VALLEY HEALTHCARE chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTEVERGREEN SNF OPERATIONS HOLDINGS LLCsince 07/01/2021
5% OR GREATER INDIRECT OWNERSHIP INTERESTCOPPER VA TRUST, EVERGREEN NOBLE PARENTCO LLC, GOLD VA TRUST, HVH EVERGREEN OPERATIONS HOLDINGS LLC, SILVER VA TRUST, MEISNER, ROBERTsince 07/01/2021
W-2 MANAGING EMPLOYEERINGSTAFF, RAMONAsince 07/01/2021
CORPORATE OFFICERIDELS, SHIMONsince 01/01/2023

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