Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
EVERGREEN HEALTH AND REHABILITATION CENTER
WINCHESTER, VA · 176 certified beds · Last Life Safety survey January 10, 2024
CMS Certification Number 495142 · first certified July 1984
Ownership
Operated by HILL VALLEY HEALTHCARE · For profit - Limited Liability company
- Ownership changed July 1, 2021 (change of ownership)to EVERGREEN HEALTH & REHABILITATION CENTER from PINNACLE SERVICES WINCHESTER, INC.
Position within VA
11 citations — more than 51% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to August 2027. This facility’s last Life Safety survey was January 2024. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 25, 2019 | 10 |
| April 14, 2022 | 0 |
| January 10, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-01-10 |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | 1 | 2019-04-25 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2019-04-25 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2019-04-25 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2019-04-25 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2019-04-25 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2019-04-25 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2019-04-25 |
What the citations cover
- Smoke Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 2
- Egress Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 10, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 26, 2024) |
April 25, 2019 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 11, 2019) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 11, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.