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Envoy Of Williamsburg, LLC

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About Envoy Of Williamsburg, LLC

General Information

Legal Business NameEnvoy Of Williamsburg, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareApril 17, 1991 (26 years)
Capacity130
Residents125
Percent Occupied96%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Envoy Of Williamsburg, LLC

Envoy Of Williamsburg, LLC
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Virginia Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

September 3, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
CManyPotential for Minimal HarmHealth InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
DFewPotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaint+InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaint+InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmHealth InspectionQuickly tell the resident's doctor the results of laboratory tests.
DFewPotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
DFewPotential for HarmHealth InspectionEnsure that residents are safe from serious medication errors.
DFewPotential for HarmHealth InspectionGive residents a notice of rights, rules, services and charges.

June 4, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
DFewPotential for HarmComplaintMake sure that all required doctor visits are made personally.
DFewPotential for HarmComplaintAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmComplaintGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintQuickly tell the resident's doctor the results of laboratory tests.
DFewPotential for HarmComplaintProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaintEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaintAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

April 17, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$105,757 fine
---Payment DenialPayment denial for 11 days
GFewActual HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
GFewActual HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
GFewActual HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmComplaintAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmComplaintProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
DFewPotential for HarmComplaintGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintQuickly tell the resident's doctor the results of laboratory tests.
DFewPotential for HarmComplaintMake sure that all required doctor visits are made personally.
DFewPotential for HarmComplaintProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaintAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaintProvide written records when a resident is transferred or discharged.
DFewPotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

August 28, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmComplaintEnsure that residents are safe from serious medication errors.
DFewPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmComplaintGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.

July 10, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$87,848 fine
---Payment DenialPayment denial for 67 days
FManyPotential for HarmHealth InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
GFewActual HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmComplaint+InspectionEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionEnsure that residents are safe from serious medication errors.
DFewPotential for HarmComplaint+InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaint+InspectionEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
DFewPotential for HarmComplaint+InspectionGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
DFewPotential for HarmComplaint+InspectionMake sure that doctors visit residents regularly, as required.
DFewPotential for HarmComplaint+InspectionEnsure 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.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaint+InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
DFewPotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionQuickly tell the resident's doctor the results of laboratory tests.
DFewPotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaint+InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmComplaint+InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmComplaint+InspectionEnsure each resident receives an accurate assessment by a qualified health professional.

January 23, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaint+InspectionEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmComplaint+InspectionEnsure 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.
ESomePotential for HarmHealth Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
ESomePotential for HarmComplaint+InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmComplaint+InspectionMake sure that doctors visit residents regularly, as required.
DFewPotential for HarmComplaint+InspectionEnsure that residents are safe from serious medication errors.
DFewPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
DFewPotential for HarmComplaint+InspectionGive or get specialized rehabilitative services per the patient's assessment or plan of care.
DFewPotential for HarmComplaint+InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
DFewPotential for HarmComplaint+InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaint+InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmComplaint+InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmHealth InspectionProtect each resident from all abuse, physical punishment, and involuntary separation from others.
DFewPotential for HarmHealth InspectionMake sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmHealth InspectionKeep complete, dated laboratory records in the resident's file.
DFewPotential for HarmHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
DFewPotential for HarmComplaint+InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmHealth InspectionReview or revise the resident's care plan after any major change in physical or mental health.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Envoy Of Williamsburg, LLC require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

55min
2hr 10min
ReportedExpected
CNA
30min
35min
ReportedExpected
LPN
40min
55min
ReportedExpected
RN
2hr 5min
3hr 40min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

99.0%
95.9%
95.9%
93.8%
Q1 2015Q2 2015Q3 2015VA
Assessed and Appropriately Given the Seasonal Influenza Vaccine
95.4%
89.4%
79.2%
92.0%
Q1 2015Q2 2015Q3 2015VA
Assessed and Appropriately Given the Pneumococcal Vaccine
26.2%
14.6%
22.0%
52.4%
Q1 2015Q2 2015Q3 2015VA
Low Risk Residents Who Lose Control of Their Bowel or Bladder
19.5%
18.7%
18.9%
17.3%
Q1 2015Q2 2015Q3 2015VA
Received an Antipsychotic Medication
29.4%
16.9%
18.5%
17.6%
Q1 2015Q2 2015Q3 2015VA
Need for Help with ADLs has Increased
10.7%
6.7%
6.0%
9.2%
Q1 2015Q2 2015Q3 2015VA
Self Report Moderate to Severe Pain
14.3%
8.0%
9.2%
7.9%
Q1 2015Q2 2015Q3 2015VA
Lose Too Much Weight
7.2%
4.3%
5.9%
6.2%
Q1 2015Q2 2015Q3 2015VA
High Risk Residents With Pressure Ulcers
0.0%
0.0%
0.0%
2.9%
Q1 2015Q2 2015Q3 2015VA
Have Depressive Symptoms
1.9%
1.8%
3.4%
6.1%
Q1 2015Q2 2015Q3 2015VA
With a Urinary Tract Infection
3.7%
2.7%
2.5%
3.5%
Q1 2015Q2 2015Q3 2015VA
Experiencing One or More Falls with Major Injury
0.0%
0.9%
0.9%
2.8%
Q1 2015Q2 2015Q3 2015VA
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015VA
Were Physically Restrained

Quality Measures for Short Stay Residents

60.3%
69.0%
54.5%
81.6%
Q1 2015Q2 2015Q3 2015VA
Assessed and Appropriately Given the Pneumococcal Vaccine
66.7%
41.3%
41.3%
81.9%
Q1 2015Q2 2015Q3 2015VA
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
17.3%
18.2%
8.6%
17.4%
Q1 2015Q2 2015Q3 2015VA
Self Report Moderate to Severe Pain
3.1%
0.0%
0.0%
2.1%
Q1 2015Q2 2015Q3 2015VA
Newly Received an Antipsychotic Medication
1.2%
0.0%
0.0%
1.0%
Q1 2015Q2 2015Q3 2015VA
With Pressure Ulcers That Are New or Worsened