Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Report Alleged Verbal Abuse Between Residents: An LPN documented a heated argument in which one resident yelled and cursed at another resident, but the incident was not reported to management or the SA as an allegation of abuse. The LPN said she separated the residents and later realized it may have been verbal abuse; the Administrator later confirmed it should have been reported and investigated.
Failure to report an allegation of verbal abuse involving two residents. An LPN witnessed one resident arguing and cursing at another resident after the second resident had been yelling earlier, separated them, and documented the event, but the incident was not reported to management or the SA as an abuse allegation. The Administrator later stated it should have been reported and investigated.
A resident with a history of alcohol abuse had repeated intoxication episodes documented by staff and the NP, including being found slurring speech, cursing, and hiding a bottle of liquor, as well as being found passed out with vodka under his chair. Although the NP documented ongoing alcohol abuse, supervised leave only, and counseling about alcohol-related risks, the care plan was not revised to reflect the recent intoxication events. Staff interviews also showed the resident was known to drink on the unit and that intoxication symptoms were not consistently documented.
Failure to provide behavioral health services for a resident with alcohol abuse. The resident was found intoxicated on multiple occasions, including one episode with a bottle hidden in his clothing and another where he was passed out with vodka under his chair. Records showed staff noted intoxication and alcohol smell, but social services did not address the incidents, there was no documented investigation into how he obtained alcohol, and there was no evidence the psychiatry NP was aware of the events.
Failure to Provide Medically Related Social Services for Alcohol Abuse: A resident with a history of alcohol abuse had repeated intoxication episodes, including being found visibly intoxicated and later passed out with a vodka bottle hidden on his person. Nursing staff reported ongoing alcohol use and suspected alcohol was being brought into the facility, but the social services assessment did not address the incidents and there was no evidence of an investigation into how the alcohol was obtained. The DOSS stated he had no knowledge of the resident’s alcohol use, and the record showed limited social services involvement despite the resident’s SUD history.
Incomplete and Inaccurate Clinical Record for Alcohol Use: A resident's chart repeatedly documented a strong odor of alcohol during NP assessments, even though the resident was observed awake and alert in bed with no odor of alcohol present. NP interviews confirmed the notes were generated using AI-assisted software that pulled historical information from the record, and one NP stated she had never smelled alcohol on the resident and that the record was not accurate.
Failure to Report Alleged Verbal Abuse Between Residents
Penalty
Summary
The facility failed to implement its policy for reporting an allegation of abuse when a verbal altercation occurred between two residents. A nursing note documented that one resident walked to another resident’s room and began arguing and cursing at the other resident because he had been yelling earlier in the day. The note was written by an LPN, and review of both residents’ clinical records and facility documents showed no evidence that the incident was reported to management or to the State Agency as an allegation of abuse. During interview, the LPN stated she separated the residents immediately and documented what she witnessed, and later recognized the event as potential verbal abuse. She said she reported the incident to a supervisor but could not remember when or to whom. Another LPN stated that a resident yelling and cursing at another resident could be considered verbal abuse and should be immediately reported. The Administrator stated he was not certain how accurate the LPN’s account was, but later acknowledged that the incident was an allegation of verbal abuse that should have been reported to the State Agency and investigated.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #8 after a verbal altercation with Resident #3. A nursing note documented that Resident #3 walked to Resident #8’s room and began arguing and cursing at Resident #8 because Resident #8 had been yelling earlier in the day. Review of the clinical records and facility documents found no evidence that the incident was reported to management or to the State Agency as an allegation of abuse. During interview, the LPN who witnessed the event stated she separated the residents and documented what she saw, and later recognized the incident as potential verbal abuse. She stated she reported it to a supervisor but could not remember when or to whom. Another LPN stated that one resident yelling and cursing at another resident could be considered verbal abuse and should be immediately reported. The Administrator stated the incident should have been conveyed to him and that it was an allegation of verbal abuse that should have been reported to the SA and investigated.
Care plan not updated after repeated intoxication episodes
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident with a history of alcohol abuse after two documented episodes of intoxication. The resident was admitted with alcohol abuse listed among his diagnoses, and the clinical record showed staff observed him intoxicated, slurring speech, cursing at staff, and pulling a bottle from inside his pants in the groin area. Staff also documented that he was found intoxicated on another occasion, passed out with a vodka bottle under his chair in a water bottle. Provider notes documented that staff reported the resident acted intoxicated, smelled of alcohol, and had previously been noted acting giggly with reports that alcohol was being brought to him at the facility. The NP documented ongoing alcohol abuse, noted that the resident had been placed in the book for supervised leave only due to alcohol use, and recorded counseling about how alcohol use interfered with hypertension management and increased risk for recurrent stroke/CVA and aspiration due to chronic dysphagia. The resident’s care plan, however, still reflected only a general history of alcoholism, risk for complications, medication administration, observation for signs and symptoms of intoxication or withdrawal, and vitals as needed. The care plan review did not include information related to the two intoxication episodes. Staff interviews indicated that the resident was known to drink, often on weekends or when visitors were present, and that alcohol use was frequently observed or suspected on the unit. One LPN stated she did not often document intoxication symptoms because she felt she could not, and another stated she smelled alcohol on the resident and had seen him remove a liquor bottle from his pants, but the weekend supervisor did not come to the unit and told her to simply take vital signs and write a note. The facility policy stated that the interdisciplinary team is responsible for reviewing and updating care plans when there is a significant change in condition or when the desired outcome is not met.
Failure to Provide Behavioral Health Services for Resident with Alcohol Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for Resident #6, who had a diagnosis of alcohol abuse and a history of ongoing alcohol use. The record showed that the resident was found intoxicated on more than one occasion, including an episode in which staff witnessed him come downstairs visibly intoxicated, slurring his speech, cursing at staff, and pulling a bottle from inside his pants in the groin area. Staff also documented another incident in which he was found intoxicated, passed out with a vodka bottle under his chair in a water bottle. Provider notes documented that staff reported intoxication, smell of alcohol, and prior reports that alcohol was being brought to the resident at the facility. One NP note stated the resident had been found intoxicated and passed out with a vodka bottle under his chair, and another note stated he had been found intoxicated with a vodka bottle under his chair in a water bottle. The resident was placed in the book for supervised leave only due to alcohol use, and the notes referenced continued vitamin support and facility monitoring/supervision. The care plan identified a history of alcoholism and directed staff to observe for signs and symptoms of intoxication or withdrawal. Despite these events, the social services quarterly assessment contained no information related to the two intoxication incidents. The record also contained no evidence of any investigation into how the resident obtained the alcohol that caused the intoxication episodes. The psychiatry NP notes showed no evidence that the resident was seen by the provider between the intoxication events, and the facility provided no evidence that the psychiatry NP was aware of them. Interviews with staff reflected uncertainty about how the resident was obtaining alcohol and how the facility was addressing substance use disorder, and the Director of Social Services stated he had no knowledge of the resident's alcohol use or intoxication incidents.
Failure to Provide Medically Related Social Services for Resident With Alcohol Abuse
Penalty
Summary
The facility failed to provide medically related social services for one resident with a history of alcohol abuse after two episodes of intoxication. The resident was admitted with alcohol abuse listed among the diagnoses, and the clinical record documented that staff found the resident visibly intoxicated, slurring speech, cursing at staff, and pulling a bottle from the groin area. Another note documented the resident intoxicated with a vodka bottle under the chair, and a later NP note stated the resident had been found intoxicated and passed out with a vodka bottle under the chair in a water bottle. The record showed that the NP documented alcohol abuse and noted that staff reported the resident acted intoxicated with the smell of alcohol and that another resident had reported alcohol being brought to him at the facility. The NP also documented counseling about alcohol abuse and discussed how alcohol use interfered with hypertension management and increased risk for stroke/CVA and aspiration due to chronic dysphagia. However, the resident’s quarterly social services assessment contained no information related to the intoxication incidents, and there was no evidence of any investigation into how the resident obtained the alcohol. Interviews showed that nursing staff were aware of ongoing alcohol use and suspected alcohol was being brought into the facility, but documentation was limited. One LPN stated the resident often drank on weekends when management staff were scarce and said she did not often document intoxication symptoms because she felt she could not. Another LPN stated she frequently smelled alcohol on the resident and believed episodes often corresponded with visitors from the community. The Director of Social Services stated he had no knowledge of the resident’s alcohol use and that nothing related to the intoxication incidents had been reported to him, while the Administrator stated the facility had difficulty maintaining social services staffing. The facility policy required a substance use disorder assessment within 48 to 72 hours of admission and social services involvement for support and relapse-related planning, but the record did not show that medically related social services were provided for the resident’s intoxication events.
Incomplete and Inaccurate Clinical Record for Alcohol Use
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for one resident regarding alcohol use. On 5/5/26 at 11:22 a.m., the resident was observed lying on his right side in bed, awake and alert, with no odor of alcohol in the room. However, the clinical record contained a Nurse Practitioner progress note dated 2/5/26 stating that a strong odor of alcohol was noted during assessment, consistent with ongoing alcohol use. The same documentation about a strong odor of alcohol appeared in identical form in subsequent NP notes on 3/3/26, 3/13/26, 3/17/26, 4/10/26, 4/15/26, 4/22/26, 4/29/26, and 5/1/26. During interviews, one NP stated the practice used software with AI that incorporated information from the resident's entire record into provider notes and that she did not read the complete note for accuracy after dictating it. Another NP stated she was responsible for the resident's notes, that the software pulled historical information from the entire clinical record and prior hospital stays, and that she had never smelled alcohol on the resident at any point in time, stating the record was not accurate.
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Illustrative
What surveyors actually found near you
We read the 44 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shenandoah Valley Westminster Canterbury | 2.3 mi | ★★★★★ | 0 | 0 |
| Winchester Health & Rehabilitation | 2.4 mi | ★★★★★ | 4 | 0 |
| The Village At Orchard Ridge | 3.3 mi | ★★★★★ | 0 | 0 |
| Rose Hill Health And Rehab | 10 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Front Royal | 15.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.