Evergreen Health and Rehabilitation Center

380 Millwood Avenue, Winchester, VA 22601

Open in maps See this home on CMS Care Compare

Evergreen Health and Rehabilitation Center is a nursing home in Winchester, Virginia. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.

At a glance

CMS overall star rating2 of 5
Last standard health inspectionJanuary 10, 2024 (2 years ago)
Health citations since April 25, 201961 (Virginia average 39)
Fines in the past three yearsNone listed by CMS
CMS flagsNone listed by CMS

This page uses data from the Centers for Medicare & Medicaid Services (CMS), published on October 28, 2026. CMS updates its data about once a month.

Get an email when CMS publishes something new about this home

One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.

Email alerts for this home open soon.

CMS flags

CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.

Inspections, fines and changes

This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.

Health inspection on May 6, 2026
6 citations
CMS lists this as a complaint inspection.
Show the 6 citations
- Citation F0607. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  CMS lists it as corrected on June 1, 2026.
- Citation F0609. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  CMS lists it as corrected on June 1, 2026.
- Citation F0657. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  CMS lists it as corrected on June 1, 2026.
  CMS has cited this home for F0657 3 times since 2019.
- Citation F0740. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  CMS lists it as corrected on June 1, 2026.
- Citation F0745. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide medically-related social services to help each resident achieve the highest possible quality of life.
  CMS lists it as corrected on June 1, 2026.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on June 1, 2026.
  CMS has cited this home for F0842 4 times since 2019.
See this home on CMS Care Compare
CMS update of February 25, 2026
- Star rating
  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of November 20, 2025
- Health citation
  CMS changed citation F0695 from severity D to E. It is from the health inspection on April 25, 2019. Severity E: potential for more than minimal harm, pattern.
CMS update of July 30, 2025
- Star rating
  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
- Star rating
  The CMS health inspection star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 30, 2025
- Star rating
  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of February 26, 2025
- Star rating
  The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of October 30, 2024
- Star rating
  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of January 31, 2024
- Fine
  CMS changed the fine from April 25, 2023 from $12,600 to $8,190.
Health inspection on January 10, 2024
22 citations
CMS lists this as a standard inspection.
Show the 22 citations
- Citation F0865. Severity F: potential for more than minimal harm, widespread.
  The rule CMS cited: Have a plan that describes the process for conducting QAPI and QAA activities.
  CMS lists it as corrected on February 19, 2024.
- Citation F0880. Severity F: potential for more than minimal harm, widespread.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0880 2 times since 2022.
- Citation F0623. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0623 3 times since 2019.
- Citation F0698. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.
  CMS lists it as corrected on February 19, 2024.
- Citation F0812. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0812 3 times since 2019.
- Citation F0840. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 19, 2024.
- Citation F0887. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 19, 2024.
- Citation F0554. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.
  CMS lists it as corrected on February 19, 2024.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0580 2 times since 2019.
- Citation F0582. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0582 2 times since 2022.
- Citation F0625. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0625 2 times since 2022.
- Citation F0641. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure each resident receives an accurate assessment.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0641 3 times since 2019.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0656 3 times since 2019.
- Citation F0658. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.
  CMS lists it as corrected on February 19, 2024.
- Citation F0687. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate foot care.
  CMS lists it as corrected on February 19, 2024.
- Citation F0688. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 19, 2024.
- Citation F0695. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0695 3 times since 2019.
- Citation F0730. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Observe each nurse aide's job performance and give regular training.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0730 3 times since 2019.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0755 2 times since 2019.
- Citation F0759. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0759 2 times since 2019.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on February 19, 2024.
- Citation F0732. Severity C: potential for minimal harm, widespread.
  The rule CMS cited: Post nurse staffing information every day.
  CMS lists it as corrected on February 19, 2024.
  CMS has cited this home for F0732 2 times since 2022.
See this home on CMS Care Compare
Fire safety inspection on January 10, 2024
1 citation
CMS lists this as a standard inspection.
Show the 1 citation
- Citation K0363. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Install corridor and hallway doors that block smoke.
  CMS lists it as corrected on March 26, 2024.
  CMS has cited this home for K0363 2 times since 2019.
See this home on CMS Care Compare
Health inspection on April 14, 2022
17 citations
CMS lists this as a standard inspection.
Show the 17 citations
- Citation F0812. Severity F: potential for more than minimal harm, widespread.
  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  CMS lists it as corrected on May 16, 2022.
- Citation F0578. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 16, 2022.
- Citation F0622. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 16, 2022.
  CMS has cited this home for F0622 2 times since 2019.
- Citation F0623. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  CMS lists it as corrected on May 16, 2022.
- Citation F0625. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 16, 2022.
- Citation F0657. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  CMS lists it as corrected on May 16, 2022.
- Citation F0730. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Observe each nurse aide's job performance and give regular training.
  CMS lists it as corrected on May 16, 2022.
- Citation F0582. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  CMS lists it as corrected on May 16, 2022.
- Citation F0641. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure each resident receives an accurate assessment.
  CMS lists it as corrected on May 16, 2022.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on May 16, 2022.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on May 16, 2022.
- Citation F0695. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS lists it as corrected on May 16, 2022.
- Citation F0700. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 16, 2022.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on May 16, 2022.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on May 16, 2022.
- Citation F0947. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  CMS lists it as corrected on May 16, 2022.
- Citation F0732. Severity C: potential for minimal harm, widespread.
  The rule CMS cited: Post nurse staffing information every day.
  CMS lists it as corrected on May 16, 2022.
See this home on CMS Care Compare
Health inspection on April 25, 2019
16 citations
CMS lists this as a standard inspection.
Show the 16 citations
- Citation F0695. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS lists it as corrected on June 21, 2019.
- Citation F0730. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Observe each nurse aide's job performance and give regular training.
  CMS lists it as corrected on May 28, 2019.
- Citation F0759. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.
  CMS lists it as corrected on May 28, 2019.
- Citation F0761. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 28, 2019.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on May 28, 2019.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on May 28, 2019.
- Citation F0622. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 28, 2019.
- Citation F0623. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  CMS lists it as corrected on May 28, 2019.
- Citation F0641. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure each resident receives an accurate assessment.
  CMS lists it as corrected on May 28, 2019.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on June 21, 2019.
- Citation F0657. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  CMS lists it as corrected on May 28, 2019.
- Citation F0697. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.
  CMS lists it as corrected on May 28, 2019.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on May 28, 2019.
- Citation F0758. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 28, 2019.
- Citation F0812. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  CMS lists it as corrected on May 28, 2019.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on June 21, 2019.
See this home on CMS Care Compare
Fire safety inspection on April 25, 2019
10 citations
CMS lists this as a standard inspection.
Show the 10 citations
- Citation K0222. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on June 11, 2019.
- Citation K0761. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
  CMS lists it as corrected on June 11, 2019.
- Citation K0923. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Have proper medical gas storage and administration areas.
  CMS lists it as corrected on June 11, 2019.
- Citation K0225. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have stairways and smokeproof enclosures used as exits that meet safety requirements.
  CMS lists it as corrected on June 11, 2019.
- Citation K0363. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Install corridor and hallway doors that block smoke.
  CMS lists it as corrected on June 11, 2019.
- Citation K0372. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
  CMS lists it as corrected on June 11, 2019.
- Citation K0711. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide a written emergency evacuation plan.
  CMS lists it as corrected on June 11, 2019.
- Citation K0901. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
  CMS lists it as corrected on June 11, 2019.
- Citation K0918. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.
  CMS lists it as corrected on June 11, 2019.
- Citation K0920. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure proper usage of power strips and extension cords.
  CMS lists it as corrected on June 11, 2019.
See this home on CMS Care Compare

CMS star ratings

2 of 5CMS overall star rating
2 of 5CMS health inspection star rating
2 of 5CMS staffing star rating
4 of 5CMS quality measures star rating

Facts from CMS

Phone: (540) 667-7010
Last standard health inspection: January 10, 2024 (2 years ago)
Certified beds: 176
Residents per day, on average: 171
Ownership type: For profit - Limited Liability company
Legal business name: Evergreen SNF Operations LLC
Chain: Hill Valley Healthcare
Takes part in: Medicare and Medicaid

More health citations than the Virginia average (61 vs 39).

Owners and managers

CMS lists these owners and managers for this home. Names are as CMS writes them.

EVERGREEN SNF OPERATIONS HOLDINGS LLC5% or greater direct ownership interest · 100% · since 07/01/2021
COPPER VA TRUST5% or greater indirect ownership interest · no percentage provided · since 07/01/2021
EVERGREEN NOBLE PARENTCO LLC5% or greater indirect ownership interest · no percentage provided · since 07/01/2021
GOLD VA TRUST5% or greater indirect ownership interest · no percentage provided · since 07/01/2021
HVH EVERGREEN OPERATIONS HOLDINGS LLC5% or greater indirect ownership interest · no percentage provided · since 07/01/2021

Show 2 more

SILVER VA TRUST5% or greater indirect ownership interest · no percentage provided · since 07/01/2021
MEISNER, ROBERT5% or greater indirect ownership interest · no percentage provided · since 07/01/2021

Questions

When was Evergreen Health and Rehabilitation Center last inspected?

CMS lists January 10, 2024 as the date of its most recent standard health inspection.

How many citations (violations) does Evergreen Health and Rehabilitation Center have?

CMS lists 61 health citations since April 25, 2019. CMS also calls these deficiencies.

Has Evergreen Health and Rehabilitation Center been fined?

CMS lists no fines for this home in the past three years.

What is the CMS star rating of Evergreen Health and Rehabilitation Center?

Its CMS overall star rating is 2 of 5.

Is Evergreen Health and Rehabilitation Center a Special Focus Facility?

No. CMS does not list it as a Special Focus Facility or a candidate.

At a glance

Get an email when CMS publishes something new about this home

CMS flags

Inspections, fines and changes

Health inspection on May 6, 2026

CMS update of February 25, 2026

CMS update of November 20, 2025

CMS update of July 30, 2025

CMS update of April 30, 2025

CMS update of February 26, 2025

CMS update of October 30, 2024

CMS update of January 31, 2024

Health inspection on January 10, 2024

Fire safety inspection on January 10, 2024

Health inspection on April 14, 2022

Health inspection on April 25, 2019

Fire safety inspection on April 25, 2019

CMS star ratings

Facts from CMS

Owners and managers

Questions

Other nursing homes in Winchester