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Evergreen Health And Rehab

📍 380 Millwood Avenue, Winchester, VA 22601 📞 (540) 667-7010 🛏️ 176 beds

Inspection History Overview

Detailed Inspection Reports

No detailed inspection reports available yet. Check back soon as we're processing new reports daily.

Fines and Penalties by Year

2021 1 penalties totaling $8,037

$8,037
Jun 15, 2021

Fine

2020 1 penalties totaling $72,202

$72,202
Dec 3, 2020

Fine

2019 1 penalties totaling $0

$0
Apr 25, 2019

Payment Denial

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Health Violations by Year

2024 22 violations

Tag 0554 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0580 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0582 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0623 E Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0625 D Jan 10, 2024

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.

✓ Corrected: Feb 19, 2024
Tag 0641 D Jan 10, 2024

Ensure each resident receives an accurate assessment.

✓ Corrected: Feb 19, 2024
Tag 0656 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0658 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0687 D Jan 10, 2024

Provide appropriate foot care.

✓ Corrected: Feb 19, 2024
Tag 0688 D Jan 10, 2024

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.

✓ Corrected: Feb 19, 2024
Tag 0695 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0698 E Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0730 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0732 C Jan 10, 2024

Post nurse staffing information every day.

✓ Corrected: Feb 19, 2024
Tag 0755 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0759 D Jan 10, 2024

Ensure medication error rates are not 5 percent or greater.

✓ Corrected: Feb 19, 2024
Tag 0812 E Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0840 E Jan 10, 2024

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.

✓ Corrected: Feb 19, 2024
Tag 0842 D Jan 10, 2024

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

✓ Corrected: Feb 19, 2024
Tag 0865 F Jan 10, 2024

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

✓ Corrected: Feb 19, 2024

2023 8 violations

Tag 0607 D Apr 25, 2023

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

✓ Corrected: Jun 19, 2023
Tag 0609 D Apr 25, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Jun 19, 2023
Tag 0658 E Apr 25, 2023

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

✓ Corrected: May 26, 2023
Tag 0686 G Apr 25, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: May 26, 2023
Tag 0710 D Apr 25, 2023

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

✓ Corrected: May 26, 2023
Tag 0725 E Apr 25, 2023

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

✓ Corrected: May 26, 2023
Tag 0760 E Apr 25, 2023

Ensure that residents are free from significant medication errors.

✓ Corrected: May 26, 2023
Tag 0925 E Apr 25, 2023

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

✓ Corrected: May 26, 2023
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2022 17 violations

Tag 0578 E Apr 14, 2022

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.

✓ Corrected: May 16, 2022
Tag 0582 D Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0622 E Apr 14, 2022

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.

✓ Corrected: May 16, 2022
Tag 0623 E Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0625 E Apr 14, 2022

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.

✓ Corrected: May 16, 2022
Tag 0641 D Apr 14, 2022

Ensure each resident receives an accurate assessment.

✓ Corrected: May 16, 2022
Tag 0656 D Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0657 E Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0689 D Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0695 D Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0700 D Apr 14, 2022

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.

✓ Corrected: May 16, 2022
Tag 0730 E Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0732 C Apr 14, 2022

Post nurse staffing information every day.

✓ Corrected: May 16, 2022
Tag 0812 F Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0842 D Apr 14, 2022

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

✓ Corrected: May 16, 2022
Tag 0880 D Apr 14, 2022

Provide and implement an infection prevention and control program.

✓ Corrected: May 16, 2022
Tag 0947 D Apr 14, 2022

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

✓ Corrected: May 16, 2022

2021 4 violations

Tag 0657 D Jul 14, 2021

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

✓ Corrected: Aug 2, 2021
Tag 0657 D Jun 15, 2021

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

Tag 0689 G Jun 15, 2021

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

✓ Corrected: Jul 5, 2021
Tag 0842 D Jun 15, 2021

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

✓ Corrected: Jul 5, 2021
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2020 1 violations

Tag 0880 K Dec 3, 2020

Provide and implement an infection prevention and control program.

2019 16 violations

Tag 0550 D Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0580 D Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0622 D Apr 25, 2019

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.

✓ Corrected: May 28, 2019
Tag 0623 D Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0641 D Apr 25, 2019

Ensure each resident receives an accurate assessment.

✓ Corrected: May 28, 2019
Tag 0656 D Apr 25, 2019

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

✓ Corrected: Jun 21, 2019
Tag 0657 D Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0695 D Apr 25, 2019

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

✓ Corrected: Jun 21, 2019
Tag 0697 D Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0730 E Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0755 D Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0758 D Apr 25, 2019

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.

✓ Corrected: May 28, 2019
Tag 0759 E Apr 25, 2019

Ensure medication error rates are not 5 percent or greater.

✓ Corrected: May 28, 2019
Tag 0761 E Apr 25, 2019

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.

✓ Corrected: May 28, 2019
Tag 0812 D Apr 25, 2019

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

✓ Corrected: May 28, 2019
Tag 0842 D Apr 25, 2019

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

✓ Corrected: Jun 21, 2019
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2018 26 violations

Tag 0580 D Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0584 E Mar 30, 2018

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

✓ Corrected: May 11, 2018
Tag 0622 D Mar 30, 2018

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.

✓ Corrected: May 11, 2018
Tag 0623 E Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0624 D Mar 30, 2018

Prepare residents for a safe transfer or discharge from the nursing home.

✓ Corrected: May 11, 2018
Tag 0625 E Mar 30, 2018

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.

✓ Corrected: May 11, 2018
Tag 0641 B Mar 30, 2018

Ensure each resident receives an accurate assessment.

✓ Corrected: May 11, 2018
Tag 0645 E Mar 30, 2018

PASARR screening for Mental disorders or Intellectual Disabilities

✓ Corrected: May 11, 2018
Tag 0655 D Mar 30, 2018

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

✓ Corrected: May 11, 2018
Tag 0656 E Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0657 E Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0658 E Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0677 D Mar 30, 2018

Provide care and assistance to perform activities of daily living for any resident who is unable.

✓ Corrected: May 11, 2018
Tag 0684 D Mar 30, 2018

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

✓ Corrected: May 11, 2018
Tag 0689 D Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0690 D Mar 30, 2018

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: May 11, 2018
Tag 0695 E Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0745 E Mar 30, 2018

Provide medically-related social services to help each resident achieve the highest possible quality of life.

✓ Corrected: May 11, 2018
Tag 0755 D Mar 30, 2018

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

✓ Corrected: May 11, 2018
Tag 0756 D Mar 30, 2018

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: May 11, 2018

2017 13 violations

Tag 0157 D Jan 26, 2017

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

✓ Corrected: Mar 3, 2017
Tag 0241 D Jan 26, 2017

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

✓ Corrected: Mar 3, 2017
Tag 0250 D Jan 26, 2017

Provide medically-related social services to help each resident achieve the highest possible quality of life.

✓ Corrected: Mar 3, 2017
Tag 0252 D Jan 26, 2017

Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.

✓ Corrected: Mar 3, 2017
Tag 0279 D Jan 26, 2017

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

✓ Corrected: Mar 3, 2017
Tag 0280 E Jan 26, 2017

Allow residents the right to participate in the planning or revision of care and treatment.

✓ Corrected: Mar 3, 2017
Tag 0282 D Jan 26, 2017

Provide care by qualified persons according to each resident's written plan of care.

✓ Corrected: Mar 3, 2017
Tag 0309 D Jan 26, 2017

Provide necessary care and services to maintain or improve the highest well being of each resident .

✓ Corrected: Mar 3, 2017
Tag 0319 D Jan 26, 2017

Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances.

✓ Corrected: Mar 3, 2017
Tag 0323 D Jan 26, 2017

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

✓ Corrected: Mar 3, 2017
Tag 0329 D Jan 26, 2017

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

✓ Corrected: Mar 3, 2017
Tag 0371 E Jan 26, 2017

Store, cook, and serve food in a safe and clean way.

✓ Corrected: Mar 3, 2017
Tag 0514 E Jan 26, 2017

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

✓ Corrected: Mar 3, 2017
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