D

EVERGREEN HEALTH AND REHABILITATION CENTER

380 MILLWOOD AVENUE, WINCHESTER, VA 22601
Score: 41 / 100

Evergreen Health And Rehabilitation Center faces challenges in its CMS ratings, earning a D grade with a score of 41/100. The facility ranks in the 33th percentile among Virginia nursing homes, suggesting significant room for improvement.

With 3.29 total nurse hours per resident per day, Evergreen Health And Rehabilitation Center falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.

Recent inspections identified 63 deficiencies at Evergreen Health And Rehabilitation Center. While none were classified as the most serious level, families should review the detailed inspection history below.

Score Breakdown

Overall CMS Rating 16 / 40 pts
2 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 8 / 20 pts
2 ★ staffing rating
Quality Measures 12 / 15 pts
4 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.29 3.8 Below Average
Registered Nurses (RN) 0.77 0.7 Average
Licensed Practical Nurses (LPN) 0.75 0.7 Average
Certified Nursing Assistants (CNA) 1.77 2.4 Below Average
Weekend Total Nursing 2.95 3.8 Below Average
Weekend RN Hours 0.60 0.7 Below Average

🔍 Inspection & Deficiency History

63
Total Deficiencies
Jan 9, 2024
Most Recent Inspection
⚪ 2 Minor 🟠 61 Moderate
View recent deficiencies (5 shown)
  • Tag 0865 Severity F
    Have a plan that describes the process for conducting QAPI and QAA activities.
    Jan 9, 2024 · Administration Deficiencies
  • Tag 0880 Severity F
    Provide and implement an infection prevention and control program.
    Jan 9, 2024 · Infection Control Deficiencies
  • Tag 0623 Severity E
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including a
    Jan 9, 2024 · Resident Rights Deficiencies
  • Tag 0698 Severity E
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    Jan 9, 2024 · Quality of Life and Care Deficiencies
  • Tag 0812 Severity E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Jan 9, 2024 · Nutrition and Dietary Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 2.0% 4.5% Better
Falls with major injury 4.0% 3.0% Worse
On antipsychotic medication 8.5% 14.5% Better
Urinary tract infections 1.1% 2.5% Better
ADL decline (daily activities) 13.1% 14.0% Average
Excessive weight loss 3.5% 7.5% Better
New/worsened incontinence 27.3% 45.0% Better

⚠️ Penalties & Fines

1 penalty recorded by CMS

Total fines: $8,190

How This Grade Was Calculated

This facility's grade of D is based on a score of 41 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 2★ → 16 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 2★ → 8 pts (max 20)
  • Quality Measures Rating: 4★ → 12 pts (max 15)
  • Penalty deductions: -5 pts
  • Fine deductions: -0 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Limited Liability company
Certified Beds
176
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
Jan 9, 2024
Deficiencies (Cycle 1)
22