Starfile / Virginia

EVERGREEN HEALTH AND REHABILITATION CENTER

380 MILLWOOD AVENUE, WINCHESTER, VA 22601 · CCN 495142

Inspection history vs Virginia & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$8,190

Number of fines

1

Number of penalties

1

Payment denials

0

Chain

Chain

HILL VALLEY HEALTHCARE

Facilities in chain

40

Chain avg overall

2.20 / 5

Inspection citations (63)1 actual harm

1. DF0554Allow residents to self-administer drugs if determined clinically appropriate.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

2. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

3. DF0582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

4. EF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

5. DF0625Notify 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.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

6. DF0641Ensure each resident receives an accurate assessment.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

7. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

8. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

9. DF0687Provide appropriate foot care.2024-01-10 · Health · corrected 2024-02-19

   Potential for more than minimal harm

10. DF0688Provide 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.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

11. DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

12. EF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

13. DF0730Observe each nurse aide's job performance and give regular training.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

14. CF0732Post nurse staffing information every day.2024-01-10 · Health · corrected 2024-02-19

    Potential for minimal harm

15. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

16. DF0759Ensure medication error rates are not 5 percent or greater.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

17. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

18. EF0840Employ 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.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

19. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

20. FF0865Have a plan that describes the process for conducting QAPI and QAA activities.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

21. FF0880Provide and implement an infection prevention and control program.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

22. EF0887Educate 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.2024-01-10 · Health · corrected 2024-02-19

    Potential for more than minimal harm

23. DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2023-04-25 · Health · corrected 2023-06-19

    Potential for more than minimal harm

24. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-04-25 · Health · corrected 2023-06-19

    Potential for more than minimal harm

25. EF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-04-25 · Health · corrected 2023-05-26

    Potential for more than minimal harm

26. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-04-25 · Health · corrected 2023-05-26

    Actual harm

27. DF0710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.2023-04-25 · Health · corrected 2023-05-26

    Potential for more than minimal harm

28. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-04-25 · Health · corrected 2023-05-26

    Potential for more than minimal harm

29. EF0760Ensure that residents are free from significant medication errors.2023-04-25 · Health · corrected 2023-05-26

    Potential for more than minimal harm

30. EF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2023-04-25 · Health · corrected 2023-05-26

    Potential for more than minimal harm

31. EF0578Honor 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.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

32. DF0582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

33. EF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

34. EF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

35. EF0625Notify 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.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

36. DF0641Ensure each resident receives an accurate assessment.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

37. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

38. EF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

39. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

40. DF0695Provide safe and appropriate respiratory care for a resident when needed.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

41. DF0700Try 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.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

42. EF0730Observe each nurse aide's job performance and give regular training.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

43. CF0732Post nurse staffing information every day.2022-04-14 · Health · corrected 2022-05-16

    Potential for minimal harm

44. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

45. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

46. DF0880Provide and implement an infection prevention and control program.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

47. DF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2022-04-14 · Health · corrected 2022-05-16

    Potential for more than minimal harm

48. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

49. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

50. DF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

51. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

52. DF0641Ensure each resident receives an accurate assessment.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

53. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2019-04-25 · Health · corrected 2019-06-21

    Potential for more than minimal harm

54. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

55. EF0695Provide safe and appropriate respiratory care for a resident when needed.2019-04-25 · Health · corrected 2019-06-21

    Potential for more than minimal harm

56. DF0697Provide safe, appropriate pain management for a resident who requires such services.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

57. EF0730Observe each nurse aide's job performance and give regular training.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

58. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

59. DF0758Implement 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.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

60. EF0759Ensure medication error rates are not 5 percent or greater.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

61. EF0761Ensure 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.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

62. DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2019-04-25 · Health · corrected 2019-05-28

    Potential for more than minimal harm

63. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2019-04-25 · Health · corrected 2019-06-21

    Potential for more than minimal harm

Ownership

Other facilities in WINCHESTER

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.