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Envoy Of Woodbridge, LLC

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About Envoy Of Woodbridge, LLC

General Information

Legal Business NameEnvoy Of Woodbridge, LLC
Ownership TypeFor Profit - Partnership
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 1, 2002 (15 years)
Capacity120
Residents104
Percent Occupied87%
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 Woodbridge, LLC

Envoy Of Woodbridge, 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

November 3, 2016 - 8 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaint+Inspection1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.
ESomePotential for HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmComplaint+InspectionAllow residents the right to participate in the planning or revision of care and treatment.
ESomePotential for HarmComplaint+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.
ESomePotential for HarmHealth InspectionEnsure that residents are fully informed and understand their health status, care and treatments.
ESomePotential for HarmComplaint+InspectionKeep residents' personal and medical records private and confidential.
ESomePotential for HarmHealth InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential 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.
ESomePotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmComplaint+InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
DFewPotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaint+InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmComplaint+InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
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 by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionKeep all essential equipment working safely.
DFewPotential for HarmHealth InspectionKeep signed and dated reports of x-rays and other diagnostic services.
DFewPotential for HarmHealth InspectionProvide or obtain laboratory services only when ordered by the attending physician.
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.

December 3, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
ESomePotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth Inspection1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.
ESomePotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
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 HarmComplaint+InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaint+InspectionGive residents a notice of rights, rules, services and charges.
DFewPotential for HarmHealth InspectionHire a qualified full-time social worker in a facility with more than 120 beds.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 InspectionEnsure the activities program is directed by a qualified professional.
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 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.
DFewPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
DFewPotential for HarmHealth InspectionKeep signed and dated reports of x-rays and other diagnostic services.
DFewPotential for HarmHealth InspectionKeep complete, dated laboratory records in the resident's file.
DFewPotential for HarmHealth InspectionMake sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor.
DFewPotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
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 InspectionEnsure residents maintain acceptable nutritional status.
DFewPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
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 or obtain laboratory services only when ordered by the attending physician.
DFewPotential for HarmHealth InspectionEnsure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements.
DFewPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.

June 25, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,950 fine

February 12, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
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 HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.

November 6, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmComplaint+InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CManyPotential for Minimal HarmHealth InspectionDispose of garbage and refuse properly.
DFewPotential for HarmComplaint+InspectionEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
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 InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmHealth InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.

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 Woodbridge, 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.

2hr 5min
2hr 20min
ReportedExpected
CNA
1hr 30min
40min
ReportedExpected
LPN
15min
1hr 5min
ReportedExpected
RN
3hr 45min
4hr 10min
ReportedExpected
Total Nursing

This facility also provides approximately 50min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

90.1%
99.0%
99.0%
99.0%
94.1%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
94.4%
96.7%
62.1%
21.1%
93.0%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
32.3%
27.3%
50.0%
60.0%
52.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of low risk long-stay residents who lose control of their bowels or bladder
17.0%
15.7%
15.3%
16.1%
23.7%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who received an antianxiety or hypnotic medication
21.0%
21.1%
36.3%
30.4%
20.8%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents whose ability to move independently worsened
20.0%
15.9%
15.2%
21.2%
16.4%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who received an antipsychotic medication
21.6%
17.6%
38.9%
19.5%
16.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents whose need for help with daily activities has increased
0.0%
0.0%
4.7%
12.6%
8.3%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who self-report moderate to severe pain
8.0%
6.7%
5.9%
4.8%
7.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who lose too much weight
7.5%
13.2%
13.8%
13.3%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of high risk long-stay residents with pressure ulcers
0.0%
0.0%
0.0%
0.0%
2.8%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents who have depressive symptoms
5.7%
5.6%
8.2%
3.3%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents with a urinary tract infection
1.1%
0.0%
3.4%
4.2%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of long-stay residents experiencing one or more falls with major injury
2.9%
4.4%
5.7%
4.3%
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

75.4%
85.9%
62.6%
39.4%
83.2%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
60.9%
89.9%
89.9%
89.9%
81.3%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
61.0%
59.4%
52.3%
44.3%
65.8%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents who made improvements in function
23.8%
17.1%
13.1%
20.0%
16.1%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents who self-report moderate to severe pain
1.3%
1.5%
3.1%
2.3%
1.9%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents who newly received an antipsychotic medication
0.5%
0.7%
0.0%
0.0%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016VA
Percentage of short-stay residents with pressure ulcers that are new or worsened