Inspection Results » Envoy of Williamsburg, LLC

Health Inspection on May 11, 2018 ^[1]

1. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-06-19)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-06-19)
   • Ensure that residents are free from significant medication errors. (Corrected 2018-06-19)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-06-19)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-06-19)
   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2018-06-19)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-06-19)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-06-19)

2. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-06-19)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-06-19)
   • Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. (Corrected 2018-06-19)
   • Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. (Corrected 2018-06-19)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-06-19)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-06-19)
   • Provide medically-related social services to help each resident achieve the highest possible quality of life. (Corrected 2018-06-19)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-06-19)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-06-19)
   • Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. (Corrected 2018-06-19)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-06-19)
   • Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. (Corrected 2018-06-19)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-06-19)
   • Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (Corrected 2018-06-19)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-06-19)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-06-19)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-06-19)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-06-19)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-06-19)
   • Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (Corrected 2018-06-19)
   • Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. (Corrected 2018-06-19)
   • Provide and implement an infection prevention and control program. (Corrected 2018-06-19)