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Envoy Of Stratford Hills

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 196
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 01/26/2012

Date of last standard health inspection: 01/26/2012
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 5
Average number of Health Deficiencies in VA: 3
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in VA: 0 - 11
Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 00/09/2012 01/08/2001 Some complete and organized clinical records on each re
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 00/09/2012 01/08/2001 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/09/2012 01/08/2001 2 Some
Assist those residents who need help with eating/drinking 00/09/2012 01/08/2001 Few grooming and personal and oral hygiene.
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure each resident receives an accurate assessment by a qualified health professional. 00/09/2012 01/08/2001 2 Few

Inspection, 00/09/2012

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. 00/09/2012 01/08/2001 2 Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 00/09/2012 01/08/2001 2 Some
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 00/09/2012 01/08/2001 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/09/2012 01/08/2001 2 Few
Keep all essential equipment working safely. 00/09/2012 01/08/2001 1 Many
Put firmly secured handrails on each side of hallways. 00/09/2012 01/08/2001 2 Some
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) 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. 00/09/2012 01/08/2001 2 Few
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/09/2012 01/08/2001 2 Many
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure 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. 00/09/2012 01/08/2001 2 Few
Ensure that residents are safe from serious medication errors. 00/09/2012 01/08/2001 2 Some
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/09/2012 01/08/2001 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide medically-related social services to help each resident achieve the highest possible quality of life. 00/09/2012 01/08/2001 2 Some
Ensure services provided by the nursing facility meet professional standards of quality. 00/09/2012 01/08/2001 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/09/2012 01/08/2001 2 Some
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 00/09/2012 01/08/2001 2 Few
Evaluate a resident 00/09/2012 01/08/2001 2 Few
Give 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. 00/09/2012 01/08/2001 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure each resident receives an accurate assessment by a qualified health professional. 00/09/2012 01/08/2001 2 Few
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. 00/09/2012 01/08/2001 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give notice to the resident before a room or roommate change. 00/09/2012 01/08/2001 2 Few

Inspection, 01/01/2005

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/01/2005 03/01/2005 2 Few

Inspection, 01/04/2003

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 01/04/2003 00/01/2004 Few complete and organized clinical records on each re
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/04/2003 00/01/2004 2 Few
Have a program that investigates 01/04/2003 00/01/2004 Few controls and keeps infection from spreading.
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep the rate of medication errors (wrong drug 01/04/2003 00/01/2004 wrong time) to less than 5%. wrong dose
Ensure that residents are safe from serious medication errors. 01/04/2003 00/01/2004 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/04/2003 00/01/2004 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure services provided by the nursing facility meet professional standards of quality. 01/04/2003 00/01/2004 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/04/2003 00/01/2004 2 Few
Develop policies and procedures for influenza and pneumococcal immunizations. 01/04/2003 00/01/2004 2 Some
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assure that each resident 01/04/2003 00/01/2004 2 Few
Allow residents the right to participate in the planning or revision of care and treatment. 01/04/2003 00/01/2004 2 Few
Maintain 15 months of resident assessments in the resident's active clinical record. 01/04/2003 00/01/2004 2 Some
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give notice to the resident before a room or roommate change. 01/04/2003 00/01/2004 2 Few

Inspection, 00/01/2002

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. 00/01/2002 01/08/2003 2 Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 00/01/2002 01/08/2003 2 Few
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/01/2002 03/00/2004 2 Some
Have a program that investigates, controls and keeps infection from spreading. 00/01/2002 01/08/2003 2 Some
Make sure that a working call system is available in each resident's room or bathroom and bathing area. 00/01/2002 01/08/2003 2 Many
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/01/2002 00/00/0000 2 Some
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) 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. 00/01/2002 01/08/2003 2 Few
1) Hire only people with no legal history of abusing 00/01/2002 00/00/0000 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. 00/01/2002 01/08/2003 2 Some
Prepare food that is nutritional 00/01/2002 00/00/0000 tasty appetizing
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that residents are safe from serious medication errors. 00/01/2002 01/08/2003 2 Few
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/01/2002 01/05/2004 2 Few
Ensure that residents are safe from serious medication errors. 00/01/2002 00/00/0000 2 Few
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/01/2002 00/00/0000 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 00/01/2002 01/08/2003 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 00/01/2002 01/08/2003 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/01/2002 01/08/2003 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/01/2002 01/08/2003 3 Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. 00/01/2002 01/05/2004 2 Few
Provide activities to meet the interests and needs of each resident. 00/01/2002 00/00/0000 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 00/01/2002 00/00/0000 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/01/2002 00/00/0000 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/01/2002 00/00/0000 3 Few
Properly care for residents needing special services 00/01/2002 00/00/0000 colostomy including: injections
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure each resident receives an accurate assessment by a qualified health professional. 00/01/2002 01/08/2003 2 Some
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. 00/01/2002 01/08/2003 2 Few
Maintain 15 months of resident assessments in the resident's active clinical record. 00/01/2002 01/08/2003 2 Few
Review or revise the resident's care plan after any major change in physical or mental health. 00/01/2002 00/00/0000 2 Few
Ensure each resident receives an accurate assessment by a qualified health professional. 00/01/2002 00/00/0000 2 Some
Provide proper discharge planning and communication 00/01/2002 00/00/0000 Few of the resident's health status and summary of the
Maintain 15 months of resident assessments in the resident's active clinical record. 00/01/2002 00/00/0000 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents a notice of rights, rules, services and charges. 00/01/2002 01/08/2003 1 Many
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 00/01/2002 01/08/2003 2 Few
Keep residents' personal and medical records private and confidential. 00/01/2002 01/08/2003 2 Few
Allow residents to self-administer drugs if determined safe. 00/01/2002 01/05/2004 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 00/01/2002 01/08/2003 2 Few
Immediately tell the resident 00/01/2002 00/00/0000 and a family member of situations (injury/decline/ the resident's doctor
Keep residents' personal and medical records private and confidential. 00/01/2002 00/00/0000 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 00/01/2002 00/00/0000 2 Few

Inspection, 02/06/2001

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. 02/06/2001 02/08/2002 2 Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 02/06/2001 00/01/2004 2 Some
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. 02/06/2001 02/08/2002 2 Few
Keep accurate 02/06/2001 00/01/2004 Some complete and organized clinical records on each re
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. 02/06/2001 02/08/2002 2 Some
Provide housekeeping and maintenance services. 02/06/2001 02/08/2002 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/06/2001 00/01/2004 2 Some
Have a program that investigates, controls and keeps infection from spreading. 02/06/2001 00/01/2004 2 Some
Provide a safe 02/06/2001 02/08/2002 comfortable and home-like environment; and allow r clean
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/06/2001 00/01/2004 2 Some
Have a program that investigates 02/06/2001 00/01/2004 Some controls and keeps infection from spreading.
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) 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. 02/06/2001 02/08/2002 2 Few
1) Hire only people with no legal history of abusing 02/06/2001 02/08/2002 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure 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. 02/06/2001 02/08/2002 2 Few
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. 02/06/2001 00/01/2004 2 Some
Ensure that residents are safe from serious medication errors. 02/06/2001 00/01/2004 2 Some
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 02/06/2001 02/08/2002 2 Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 02/06/2001 00/01/2004 2 Few
Ensure 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. 02/06/2001 02/08/2002 2 Few
Keep the rate of medication errors (wrong drug 02/06/2001 00/01/2004 wrong time) to less than 5%. wrong dose
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 02/06/2001 02/08/2002 2 Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 02/06/2001 00/01/2004 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide medically-related social services to help each resident achieve the highest possible quality of life. 02/06/2001 02/08/2002 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 02/06/2001 00/01/2004 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 02/06/2001 00/01/2004 2 Some
Ensure 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. 02/06/2001 02/08/2002 2 Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. 02/06/2001 02/08/2002 2 Some
Develop policies and procedures for influenza and pneumococcal immunizations. 02/06/2001 00/01/2004 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 02/06/2001 00/01/2004 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 02/06/2001 00/01/2004 2 Some
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assure that each resident 02/06/2001 00/01/2004 2 Some
Ensure each resident receives an accurate assessment by a qualified health professional. 02/06/2001 02/08/2002 2 Some
Allow residents the right to participate in the planning or revision of care and treatment. 02/06/2001 00/01/2004 2 Some
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. 02/06/2001 02/08/2002 2 Few
Maintain 15 months of resident assessments in the resident's active clinical record. 02/06/2001 00/01/2004 2 Some
Ensure each resident receives an accurate assessment by a qualified health professional. 02/06/2001 02/08/2002 2 Some
Allow residents the right to participate in the planning or revision of care and treatment. 02/06/2001 00/01/2004 2 Some
Maintain 15 months of resident assessments in the resident's active clinical record. 02/06/2001 00/01/2004 2 Some
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide written records when a resident is transferred or discharged. 02/06/2001 02/08/2002 2 Few
Give notice to the resident before a room or roommate change. 02/06/2001 00/01/2004 2 Few
Provide written records when a resident is transferred or discharged. 02/06/2001 02/08/2002 2 Few

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in VA Golden Living Center, Asheville
RN Staff Only1 N/A N/A 3 out of 5 stars
Total Number of Residents 86 98 172
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 9 hours 34 minutes 1 hour 30 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 8 hours 32 minutes 36 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 8 hours 57 minutes 54 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 10 hours 8 minutes 1 hour 59 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 02/01/2012

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 02/01/2012
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in VA: 0
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in VA: 0 - 0

Inspection, 01/07/2012

Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridor and hallway doors that block smoke. 01/07/2012 00/09/2002 2 Few

Inspection, 01/04/2002

Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridor and hallway doors that block smoke. 01/04/2002 03/00/2004 2 Some

Inspection, 00/01/2002

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved automatic sprinkler system connected to the fire alarm system. 00/01/2002 01/06/2003 2 Few
Building Service Equipment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly protected cooking facilities. 00/01/2002 01/06/2003 2 Few
Smoking Regulations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Posted No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed." 00/01/2002 01/06/2003 2 Few
 

7246 Forest Hill Avenue
Richmond, VA 23225

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