Your report for Evergreen Health and Rehabilitation Center
Overall Score
CMS Five-Star Quality RatingBelow averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- VirginiaAbove only 22% of peers285 rated homes · average 3.0★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs VA avg
- StaffingCan add or remove a star2★−0.5 vs VA avg
- Quality measuresCan add or remove a star4★+0.1 vs VA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Standard inspection overdueThe most recent standard health inspection is older than CMS expects, so the health inspection rating may not reflect current conditions.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 21% of peersVA avg2.8★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 30% of peersVA avg2.5★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 33% of peersVA avg3.9★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.29hrsAbove only 31% of peersVA avg3.82Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.77hrsAbove 79% of peersVA avg0.69Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better52%Above only 40% of peersVA avg48%RN turnover59%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$8,190Above only 30% of peersVA avg$16,279Fines · denials1 · 0
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles63citations
4inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Jan 10, 2024most recent
Citations by monthApr 2019 – Jan 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jan 10, 2024Cycle 1worst F · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Feb 19, 2024
- F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Feb 19, 2024
- F688Provide 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.Quality of Life and CareD · isolatedCorrected Feb 19, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Feb 19, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Feb 19, 2024
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Feb 19, 2024
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Feb 19, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 19, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Feb 19, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Feb 19, 2024
- F887Educate 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.Infection ControlE · patternCorrected Feb 19, 2024
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Feb 19, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 19, 2024
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Feb 19, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Feb 19, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Feb 19, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Feb 19, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Feb 19, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 19, 2024
- F840Employ 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.AdministrationE · patternCorrected Feb 19, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Feb 19, 2024
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationF · widespreadCorrected Feb 19, 2024
Apr 25, 2023Cycle 3worst G · actual harm$8,190
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 19, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 19, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected May 26, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected May 26, 2023
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesD · isolatedCorrected May 26, 2023
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected May 26, 2023
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected May 26, 2023
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected May 26, 2023
Apr 14, 2022Cycle 2worst F · no actual harm
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesD · isolatedCorrected May 16, 2022
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected May 16, 2022
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected May 16, 2022
- F578Honor 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.Resident RightsE · patternCorrected May 16, 2022
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected May 16, 2022
- F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsE · patternCorrected May 16, 2022
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected May 16, 2022
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 16, 2022
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 16, 2022
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected May 16, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 16, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 16, 2022
- F700Try 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.Quality of Life and CareD · isolatedCorrected May 16, 2022
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected May 16, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 16, 2022
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 16, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 16, 2022
Apr 25, 2019Cycle 3worst E · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 28, 2019
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 28, 2019
- F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected May 28, 2019
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected May 28, 2019
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 28, 2019
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jun 21, 2019
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected May 28, 2019
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Jun 21, 2019
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 28, 2019
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected May 28, 2019
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 28, 2019
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 28, 2019
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected May 28, 2019
- F761Ensure 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.Pharmacy ServiceE · patternCorrected May 28, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected May 28, 2019
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jun 21, 2019
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.29hrs
- Registered nursesRN hours only0.77hrs
- Licensed practical nursesLPN hours0.75hrs
- Nurse aidesCNA hours1.77hrs
- Weekend nursingAll staff on Saturdays and Sundays2.95hrs
- Virginia average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better52%Above only 40% of peersVA avg 48%
- RN turnoverRegistered nurses only59%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy176 certified beds · ~168 residents a day95%Above 87% of peersVA avg 87%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $8,190In fines
- 1Fine
- 0Payment denials
- $16,279VA avg in fines
Above only 30% of peersFewer fines than 30% of rated homes in Virginia
Actions on record
- Apr 25, 2023Civil money penalty$8,190
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Hill Valley Healthcare39 facilities in the chain2.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Evergreen SNF Operations Holdings LLC
Indirect owners (5%+)
- Copper VA Trust
- Evergreen Noble Parentco LLC
- Gold VA Trust
- Hvh Evergreen Operations Holdings LLC
- Lion 26 Holdings LLC
- Sabrina 1818 Holdings LLC
- Saessy Irrevocable Trust
- Silver VA Trust
- +2 more
Corporate officers
- Shimon Idels
Managing employees
- Ramona Ringstaff
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 495142 · 380 MILLWOOD AVENUE, WINCHESTER, VA, 22601.
- Percentiles compare this facility with every rated nursing home in Virginia and Winchester City County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
