Public Record
Evergreen Health and Rehabilitation Center
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 176
- Avg. residents per day
- 171.1
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 73
- Inspections on file
- 6
- Last inspection
- 2024-01-10
*CMS
*CMS
*CMS
Citations
73 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0840Generalpotential for harm
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.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0865Generalpotential for harm
Have a plan that describes the process for conducting QAPI and QAA activities.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0887Generalpotential for harm
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.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0625Generalpotential for harm
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.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0687Generalpotential for harm
Provide appropriate foot care.
- 0688Generalpotential for harm
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.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0710Generalpotential for harm
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0578Generalpotential for harm
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.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0622Generalpotential for harm
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.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0625Generalpotential for harm
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.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0700Generalpotential for harm
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.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0622Generalpotential for harm
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.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0758Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0222Generalpotential for harm
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.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0711Generalpotential for harm
Provide a written emergency evacuation plan.
- 0901Generalpotential for harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection23 deficiencies
- View inspection reportInspection23 deficiencies
- View inspection reportInspection8 deficiencies
- View inspection reportInspection17 deficiencies
- View inspection reportInspection25 deficiencies
- View inspection reportInspection25 deficiencies
FAQ
Questions and answers
- What is Evergreen Health and Rehabilitation Center?
- Evergreen Health and Rehabilitation Center is a Medicare- and Medicaid-certified nursing home in Winchester, VA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 495142.
- What is the CMS rating for Evergreen Health and Rehabilitation Center?
- Evergreen Health and Rehabilitation Center has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Evergreen Health and Rehabilitation Center have?
- Evergreen Health and Rehabilitation Center is certified for 176 beds. It serves an average of 171.1 residents per day.
- How many citations does Evergreen Health and Rehabilitation Center have?
- Evergreen Health and Rehabilitation Center has 73 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Evergreen Health and Rehabilitation Center last inspected?
- Evergreen Health and Rehabilitation Center was last inspected on January 10, 2024. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/495142-evergreen-health-and-rehabilitation-center