Federal inspection record · CMS data as of October 1, 2026
Evergreen Health And Rehabilitation Center
380 Millwood Avenue, Winchester, VA · (540) 667-7010
- Certified beds
- 176
- Residents per day
- 171
- Ownership
- For-Profit
- Chain
- Hill Valley Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 1, 1984
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Virginia.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Virginia homes
Evergreen Health And Rehabilitation Center carries 139 inspection points. That is fewer than 25% of Virginia's 287 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Virginia: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–16 pts
- 4★ 16–45 pts
- 3★ 45–76.5 pts
- 2★ 76.5–168.75 pts
- 1★ over 168.75 pts
Bars show every rated home in Virginia by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
61 health citations on record since 2019. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Resident Assessment and Care Planning14E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Rights14E
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 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.
- 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.
- 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.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 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.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 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.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Quality of Life and Care11E
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide appropriate foot care.
- 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.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- 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.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Nursing and Physician Services6E
- D
Observe each nurse aide's job performance and give regular training.
- C
Post nurse staffing information every day.
- E
Observe each nurse aide's job performance and give regular training.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- C
Post nurse staffing information every day.
- E
Observe each nurse aide's job performance and give regular training.
Pharmacy Service6E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- E
Ensure medication error rates are not 5 percent or greater.
- 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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 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.
Infection Control3F
- F
Provide and implement an infection prevention and control program.
- 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.
- D
Provide and implement an infection prevention and control program.
Nutrition and Dietary3F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Administration2F
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
- 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.
Inspection history
2024-01-10
28 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2022-04-14
17 health deficiencies · 0 fire-safety deficiencies
Top issue: Resident Rights (5 deficiencies)
2019-04-25
16 health deficiencies · 10 fire-safety deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 12 min of nursing staff time a day, 46 min of it from a registered nurse.
This home
3 h 12 min
Virginia average
3 h 53 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 48% of nursing staff and 49% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.6 pts worse | 2.0 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.1 pts better | 1.3 | 1.4 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine8.5 pts better | 99.7% | 91.2% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.5 pts better | 98.8% | 93.3% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.6 pts worse | 4.1% | 3.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms17.5 pts worse | 38.0% | 20.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight2 pts better | 3.3% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication1.2 pts worse | 21.9% | 20.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.3 pts better | 11.9% | 14.2% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1.4 pts better | 12.8% | 14.2% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.4 pts better | 14.1% | 14.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts worse | 0.9% | 0.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.6 pts better | 1.0% | 1.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.9 pts worse | 27.2% | 21.3% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.8 pts better | 1.6% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine13.1 pts better | 87.3% | 74.2% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit3.2 pts better | 8.3% | 11.5% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.4 pts worse | 1.7% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine8.8 pts better | 82.1% | 73.3% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.5 pts better | 17.5% | 22.0% | 23.4% |
·
Who owns and runs it
9 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Evergreen SNF Operations Holdings LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Copper Va Trust | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 2 facilities |
| Evergreen Noble Parentco LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 1 facilities |
| Gold Va Trust | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 2 facilities |
| Hvh Evergreen Operations Holdings LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 1 facilities |
| Idels, Shimon | Corporate Officer · Individual | 0% | 49 facilities |
| Meisner, Robert | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 10 facilities |
| Ringstaff, Ramona | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Silver Va Trust | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 2 facilities |
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Fire safety
11 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke3D
- D
Install corridor and hallway doors that block smoke.
- D
Install corridor and hallway doors that block smoke.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems3E
- E
Have proper medical gas storage and administration areas.
- D
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
Egress2E
- 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.
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Miscellaneous2E
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Provide a written emergency evacuation plan.
Electrical1D
- D
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
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Other homes nearby
-
Shenandoah Valley Westminster Canterbury
Winchester, VA
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 5 h 50 min
- Fines
- $0
-
Winchester Health & Rehabilitation
Winchester, VA · Hill Valley Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 10 min
- Fines
- $0
-
The Village At Orchard Ridge
Winchester, VA · National Lutheran Communities & Services
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 2 min
- Fines
- $0