ENVOY OF WESTOVER HILLS - RICHMOND, VA

Staff Information

Quality Measures

Complaint Deficiency

• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• A separate and independent backup electrical power source
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Review or revise the resident's care plan after any major change in a resident's physical or mental health
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Proper backup exit lighting
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Resident room doors of proper design and width
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Fire-resistant interior walls
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Limit the charges against the personal funds of a resident for items or services for which payment is made under Medicare or Medicaid
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident's personal and medical records private and confidential
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give notice to the resident before a room or roommate change
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide a safe, clean, comfortable and homelike environment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure each resident receives an accurate assessment by a qualified health professional
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Actual harm
  • Scope: Few
• 1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that residents are safe from serious medication errors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Use a registered nurse at least 8 hours a day, 7 days a week
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Put firmly secured handrails on each side of hallways
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Operate and provide services according to Federal, State, and local laws and professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Rooms that can be unlocked from inside without a key
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide activities to meet the interests and needs of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure each resident receives an accurate assessment by a qualified health professional
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Try to resolve each resident's complaints quickly
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Determine if it is safe for the resident to self-administer drugs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide medically-related social services to help each resident achieve the highest possible quality of life
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Review or revise the resident's care plan after any major change in a resident's physical or mental health
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Check and assess each resident's assessment at least every 3 months
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure each resident receives an accurate assessment by a qualified health professional
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Allow the resident the right to participate in the planning or revision of the resident's care plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Give or get quality lab services/tests in a timely manner to meet the needs of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Quickly tell the resident's doctor the results of lab tests
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Portable fire extinguishers
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some