Virginia ›Winchester

Evergreen Health and Rehabilitation Center

380 Millwood Avenue, Winchester, VA 22601 · Winchester City County · 176 certified beds · avg 172 residents/day · certified since Jul 1, 1984

Part of chain: HILL VALLEY HEALTHCARE (43 facilities, chain avg rating 1.8★)

2/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
2.69
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (61)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
May 6, 2026D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
May 6, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
May 6, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
May 6, 2026D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
May 6, 2026D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
May 6, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jan 10, 2024F · Potential for harm, facility-wideThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them.
Jan 10, 2024F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 10, 2024E · Potential for harm, repeatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jan 10, 2024E · Potential for harm, repeatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jan 10, 2024E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 10, 2024E · Potential for harm, repeatedThe facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff.
Jan 10, 2024E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Jan 10, 2024D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Jan 10, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jan 10, 2024D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Jan 10, 2024D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Jan 10, 2024D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 10, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jan 10, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 10, 2024D · Potential for harm, one-offThe facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults.
Jan 10, 2024D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jan 10, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jan 10, 2024D · Potential for harm, one-offThe facility did not observe each nurse aide's job performance or provide regular training as required.
Jan 10, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 10, 2024D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jan 10, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jan 10, 2024C · Minimal risk, facility-wideThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Apr 14, 2022F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 14, 2022E · Potential for harm, repeatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Apr 14, 2022E · Potential for harm, repeatedThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Apr 14, 2022E · Potential for harm, repeatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Apr 14, 2022E · Potential for harm, repeatedThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Apr 14, 2022E · Potential for harm, repeatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 14, 2022E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required.
Apr 14, 2022D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Apr 14, 2022D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 14, 2022D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Apr 14, 2022D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 14, 2022D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Apr 14, 2022D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Apr 14, 2022D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Apr 14, 2022D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 14, 2022D · Potential for harm, one-offThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
Apr 14, 2022C · Minimal risk, facility-wideThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Apr 25, 2019E · Potential for harm, repeatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Apr 25, 2019E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required.
Apr 25, 2019E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Apr 25, 2019E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 25, 2019D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 25, 2019D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Apr 25, 2019D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Apr 25, 2019D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Apr 25, 2019D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 25, 2019D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Apr 25, 2019D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 25, 2019D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Apr 25, 2019D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 25, 2019D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 25, 2019D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 25, 2019D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (17 → 22).

YearCitationsSerious (G–L)Worst severity that year
2019160E
2022170F
2024220F
202660D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityVirginia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)2.693.673.95bottom 7% in Virginia; bottom 6% in the U.S.
Registered Nurse hours0.690.660.69top 23% in Virginia; top 37% in the U.S.
Weekend total nurse staffing2.493.213.50bottom 17% in Virginia; bottom 9% in the U.S.
Weekend RN hours (not acuity-adjusted)0.630.460.48top 14% in Virginia; top 21% in the U.S.
Total nursing staff turnover (%)49.748.145.8bottom 46% in Virginia; bottom 38% in the U.S.
RN turnover (%)54.848.242.9bottom 38% in Virginia; bottom 28% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.16, RN 0.81, weekend 2.93. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Copper VA TrustOrganization5% or Greater Indirect Ownership Interest—07/01/2021
Evergreen Noble Parentco LLCOrganization5% or Greater Indirect Ownership Interest—07/01/2021
Evergreen SNF Operations Holdings LLCOrganization5% or Greater Direct Ownership Interest100%07/01/2021
Gold VA TrustOrganization5% or Greater Indirect Ownership Interest—07/01/2021
HVH Evergreen Operations Holdings LLCOrganization5% or Greater Indirect Ownership Interest—07/01/2021
Meisner, RobertIndividual5% or Greater Indirect Ownership Interest—07/01/2021
Silver VA TrustOrganization5% or Greater Indirect Ownership Interest—07/01/2021
Idels, ShimonIndividualCorporate OfficerNOT APPLICABLE01/01/2023
Ringstaff, RamonaIndividualW-2 Managing EmployeeNOT APPLICABLE07/01/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Shenandoah Valley Westminster Canterbury2.3 miWinchester, VA★★★★☆3/5
Winchester Health & Rehabilitation2.4 miWinchester, VA★☆☆☆☆1/5
The Village at Orchard Ridge3.3 miWinchester, VA★★★★★4/5
Rose Hill Health and Rehab10.0 miBerryville, VA★☆☆☆☆2/5
Heritage Hall Front Royal15.6 miFront Royal, VA★★★★★5/5
Lynn Care Center16.7 miFront Royal, VA★★☆☆☆1/5abuse
Willow Tree Healthcare Center18.3 miCharles Town, WV★★★☆☆3/5
Shenandoah Center19.0 miCharles Town, WV★★☆☆☆2/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 495142.