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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
Residents120
Percent Occupied92%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
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 1 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

June 24, 2016 - 12 months ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$131,286 fine
---Payment DenialPayment denial for 32 days
GFewActual HarmHealth InspectionProtect each resident from all abuse, physical punishment, and involuntary separation from others.
GFewActual HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmComplaint+InspectionEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmHealth InspectionProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
ESomePotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionUse a registered nurse at least 8 hours a day, 7 days a week.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionTrain all employees on what to do in an emergency, and carry out unannounced staff drills.
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+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
DFewPotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmHealth InspectionEnsure that all nurse aids who have worked less than 4 months are enrolled in appropriate training or have been deemed competent to provide nursing and nursing related services.
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 InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmHealth InspectionProtect each resident from mistreatment, neglect and misappropriation of personal property.
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 InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
DFewPotential for HarmHealth InspectionAssure that each residentís assessment is updated at least once every 3 months.
DFewPotential for HarmHealth 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 InspectionGive the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances.
DFewPotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

September 3, 2015 - 2 years 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$68,250 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 - 3 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 - 3 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.

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.

40min
2hr 15min
ReportedExpected
CNA
50min
40min
ReportedExpected
LPN
25min
1hr 10min
ReportedExpected
RN
1hr 55min
4hr 5min
ReportedExpected
Total Nursing

This facility also provides approximately 10min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

95.9%
79.8%
79.8%
79.8%
94.1%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
54.1%
70.7%
67.2%
57.3%
93.0%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
28.8%
38.6%
42.4%
40.6%
52.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of low risk long-stay residents who lose control of their bowels or bladder
30.0%
23.5%
28.2%
27.8%
23.7%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who received an antianxiety or hypnotic medication
39.3%
15.1%
23.0%
15.7%
20.8%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents whose ability to move independently worsened
22.3%
17.5%
21.8%
15.7%
16.4%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who received an antipsychotic medication
34.7%
18.1%
18.4%
13.6%
16.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents whose need for help with daily activities has increased
3.3%
7.0%
8.5%
7.7%
8.3%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who self-report moderate to severe pain
6.6%
11.4%
9.5%
6.0%
7.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who lose too much weight
5.8%
11.3%
6.0%
13.9%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of high risk long-stay residents with pressure ulcers
0.0%
0.0%
1.0%
0.0%
2.8%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who have depressive symptoms
2.5%
7.3%
5.2%
4.3%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents with a urinary tract infection
1.6%
3.3%
5.2%
3.4%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents experiencing one or more falls with major injury
1.9%
2.3%
0.7%
1.6%
2.1%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

36.1%
21.2%
25.8%
22.5%
83.2%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
41.3%
27.3%
27.3%
27.3%
81.3%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
65.8%
Q4 2015Q1 2016Q2 2016Q3 2016VA
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
14.8%
4.3%
-
18.2%
16.1%
Q4 2015Q1 2016Q2 2016Q3 2016VA
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
0.0%
-
-
-
1.9%
Q4 2015Q1 2016Q2 2016Q3 2016VA
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who newly received an antipsychotic medication
2.6%
5.6%
2.2%
6.8%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents with pressure ulcers that are new or worsened