Facility Watch Inspection records for every certified US nursing home

Evergreen Health and Rehabilitation Center

380 Millwood Avenue
Winchester, VA 22601
(540) 667-7010

CCN
495142
Certified beds
176
Ownership
For profit - Limited Liability company
Chain
Hill Valley Healthcare

Nurse staffing

2.71
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.65 hours per resident per day

Nursing staff turnover: 52% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected January 10, 2024

22 citations · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0554 No actual harm with potential for more than minimal harm · Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0582 No actual harm with potential for more than minimal harm · Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0625 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0730 No actual harm with potential for more than minimal harm · Isolated

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected February 19, 2024
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected February 19, 2024
E
F0623 No actual harm with potential for more than minimal harm · Pattern

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected February 19, 2024
E
F0698 No actual harm with potential for more than minimal harm · Pattern

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected February 19, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected February 19, 2024
E
F0840 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected February 19, 2024
E
F0887 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected February 19, 2024
F
F0865 No actual harm with potential for more than minimal harm · Widespread

Have a plan that describes the process for conducting QAPI and QAA activities.

Deficient, Provider has date of correction · corrected February 19, 2024
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected February 19, 2024

Inspected April 14, 2022

17 citations · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0582 No actual harm with potential for more than minimal harm · Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0700 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected May 16, 2022
D
F0947 No actual harm with potential for more than minimal harm · Isolated

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Deficient, Provider has date of correction · corrected May 16, 2022
E
F0578 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected May 16, 2022
E
F0622 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected May 16, 2022
E
F0623 No actual harm with potential for more than minimal harm · Pattern

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected May 16, 2022
E
F0625 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected May 16, 2022
E
F0657 No actual harm with potential for more than minimal harm · Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected May 16, 2022
E
F0730 No actual harm with potential for more than minimal harm · Pattern

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected May 16, 2022
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected May 16, 2022

Inspected April 25, 2019

16 citations · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0622 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected June 21, 2019
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0697 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0812 No actual harm with potential for more than minimal harm · Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected May 28, 2019
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected June 21, 2019
E
F0695 No actual harm with potential for more than minimal harm · Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected June 21, 2019
E
F0730 No actual harm with potential for more than minimal harm · Pattern

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected May 28, 2019
E
F0759 No actual harm with potential for more than minimal harm · Pattern

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected May 28, 2019
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected May 28, 2019

Ownership transfers

EffectiveSellerBuyer
07/01/2021Pinnacle Services Winchester, Inc.Evergreen SNF Operations LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.