ENVOY OF WINCHESTER, LLC

📍 110 LAUCK DR, winchester, VA 22603 📞 5406677830 🛏️ 60 beds

Overall Rating

⭐⭐
2/5

Health Inspection

⭐⭐
2/5

Staffing

⭐⭐
2/5

Quality Measures

⭐⭐⭐
3/5

Inspection History Overview

94
Total Violations
5 years of data
$11,167
Total Fines
3 penalties
3
Inspections
Since 2014
21
Quality Metrics
Tracked measures

Health Violations by Year

2023 30 violations

Tag 0580 E Apr 12, 2023

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

✓ Corrected: May 26, 2023
Tag 0607 E Apr 12, 2023

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

✓ Corrected: May 26, 2023
Tag 0622 D Apr 12, 2023

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

✓ Corrected: May 26, 2023
Tag 0623 D Apr 12, 2023

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: May 26, 2023
Tag 0625 D Apr 12, 2023

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

✓ Corrected: May 26, 2023
Tag 0640 B Apr 12, 2023

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

✓ Corrected: May 26, 2023
Tag 0655 D Apr 12, 2023

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

✓ Corrected: May 26, 2023
Tag 0656 E Apr 12, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: May 26, 2023
Tag 0657 D Apr 12, 2023

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: May 26, 2023
Tag 0658 E Apr 12, 2023

Ensure services provided by the nursing facility meet professional standards of quality.

✓ Corrected: May 26, 2023
Tag 0677 E Apr 12, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

✓ Corrected: May 26, 2023
Tag 0686 E Apr 12, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: May 26, 2023
Tag 0689 D Apr 12, 2023

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: May 26, 2023
Tag 0691 E Apr 12, 2023

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

✓ Corrected: May 26, 2023
Tag 0695 E Apr 12, 2023

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: May 26, 2023
Tag 0697 D Apr 12, 2023

Provide safe, appropriate pain management for a resident who requires such services.

✓ Corrected: May 26, 2023
Tag 0698 E Apr 12, 2023

Provide safe, appropriate dialysis care/services for a resident who requires such services.

✓ Corrected: May 26, 2023
Tag 0700 D Apr 12, 2023

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

✓ Corrected: May 26, 2023
Tag 0725 D Apr 12, 2023

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

✓ Corrected: May 26, 2023
Tag 0727 E Apr 12, 2023

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: May 26, 2023

2021 25 violations

Tag 0583 D Sep 9, 2021

Keep residents' personal and medical records private and confidential.

✓ Corrected: Oct 14, 2021
Tag 0584 D Sep 9, 2021

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: Oct 14, 2021
Tag 0622 E Sep 9, 2021

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

✓ Corrected: Oct 14, 2021
Tag 0623 D Sep 9, 2021

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Oct 14, 2021
Tag 0625 D Sep 9, 2021

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

✓ Corrected: Oct 14, 2021
Tag 0641 D Sep 9, 2021

Ensure each resident receives an accurate assessment.

✓ Corrected: Oct 14, 2021
Tag 0656 E Sep 9, 2021

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Oct 14, 2021
Tag 0657 D Sep 9, 2021

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Oct 14, 2021
Tag 0658 D Sep 9, 2021

Ensure services provided by the nursing facility meet professional standards of quality.

✓ Corrected: Oct 14, 2021
Tag 0684 D Sep 9, 2021

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

✓ Corrected: Oct 14, 2021
Tag 0686 D Sep 9, 2021

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Oct 14, 2021
Tag 0688 D Sep 9, 2021

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

✓ Corrected: Oct 14, 2021
Tag 0689 D Sep 9, 2021

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Oct 14, 2021
Tag 0697 E Sep 9, 2021

Provide safe, appropriate pain management for a resident who requires such services.

✓ Corrected: Oct 14, 2021
Tag 0700 D Sep 9, 2021

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

✓ Corrected: Oct 14, 2021
Tag 0726 D Sep 9, 2021

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

✓ Corrected: Oct 14, 2021
Tag 0727 C Sep 9, 2021

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: Oct 14, 2021
Tag 0732 C Sep 9, 2021

Post nurse staffing information every day.

✓ Corrected: Oct 14, 2021
Tag 0755 D Sep 9, 2021

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Oct 14, 2021
Tag 0761 D Sep 9, 2021

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: Oct 14, 2021

2020 16 violations

Tag 0880 D Jun 17, 2020

Provide and implement an infection prevention and control program.

✓ Corrected: Jul 20, 2020
Tag 0550 D Jan 9, 2020

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Feb 15, 2020
Tag 0623 D Jan 9, 2020

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Feb 15, 2020
Tag 0625 D Jan 9, 2020

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

✓ Corrected: Feb 15, 2020
Tag 0655 D Jan 9, 2020

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

✓ Corrected: Feb 15, 2020
Tag 0656 D Jan 9, 2020

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Feb 15, 2020
Tag 0657 D Jan 9, 2020

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Feb 15, 2020
Tag 0684 D Jan 9, 2020

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

✓ Corrected: Feb 15, 2020
Tag 0689 D Jan 9, 2020

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Feb 15, 2020
Tag 0695 E Jan 9, 2020

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Feb 15, 2020
Tag 0757 E Jan 9, 2020

Ensure each resident’s drug regimen must be free from unnecessary drugs.

✓ Corrected: Feb 15, 2020
Tag 0759 D Jan 9, 2020

Ensure medication error rates are not 5 percent or greater.

✓ Corrected: Feb 15, 2020
Tag 0760 D Jan 9, 2020

Ensure that residents are free from significant medication errors.

✓ Corrected: Feb 15, 2020
Tag 0812 E Jan 9, 2020

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Feb 15, 2020
Tag 0842 D Jan 9, 2020

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

✓ Corrected: Feb 15, 2020
Tag 0880 E Jan 9, 2020

Provide and implement an infection prevention and control program.

✓ Corrected: Feb 15, 2020

2018 13 violations

Tag 0550 D Oct 12, 2018

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Nov 10, 2018
Tag 0622 E Oct 12, 2018

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

✓ Corrected: Nov 10, 2018
Tag 0623 E Oct 12, 2018

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Nov 10, 2018
Tag 0625 E Oct 12, 2018

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

✓ Corrected: Nov 10, 2018
Tag 0655 D Oct 12, 2018

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

✓ Corrected: Nov 10, 2018
Tag 0656 D Oct 12, 2018

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Nov 10, 2018
Tag 0658 D Oct 12, 2018

Ensure services provided by the nursing facility meet professional standards of quality.

✓ Corrected: Nov 10, 2018
Tag 0693 D Oct 12, 2018

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

✓ Corrected: Nov 10, 2018
Tag 0695 E Oct 12, 2018

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Nov 10, 2018
Tag 0804 B Oct 12, 2018

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

✓ Corrected: Nov 10, 2018
Tag 0812 F Oct 12, 2018

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Nov 10, 2018
Tag 0842 D Oct 12, 2018

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

✓ Corrected: Nov 10, 2018
Tag 0880 D Oct 12, 2018

Provide and implement an infection prevention and control program.

✓ Corrected: Nov 10, 2018

2017 10 violations

Tag 0164 D Aug 3, 2017

Keep residents' personal and medical records private and confidential.

✓ Corrected: Sep 5, 2017
Tag 0226 D Aug 3, 2017

Develop 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.

✓ Corrected: Sep 5, 2017
Tag 0272 D Aug 3, 2017

Conduct initial and periodic assessments of each resident's functional capacity.

✓ Corrected: Sep 5, 2017
Tag 0279 D Aug 3, 2017

Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Sep 5, 2017
Tag 0281 D Aug 3, 2017

Ensure services provided by the nursing facility meet professional standards of quality.

✓ Corrected: Sep 5, 2017
Tag 0333 D Aug 3, 2017

Ensure that residents are safe from serious medication errors.

✓ Corrected: Sep 5, 2017
Tag 0431 D Aug 3, 2017

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

✓ Corrected: Sep 5, 2017
Tag 0441 D Aug 3, 2017

Have a program that investigates, controls and keeps infection from spreading.

✓ Corrected: Sep 5, 2017
Tag 0465 D Aug 3, 2017

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

✓ Corrected: Sep 5, 2017
Tag 0514 D Aug 3, 2017

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

✓ Corrected: Sep 5, 2017

Detailed Inspection Reports

No detailed inspection reports available yet. Check back soon as we're processing new reports daily.

Fines and Penalties by Year

2022 1 penalties totaling $994

$994
Fine
April 4, 2022
Average: $994 | Range: $994 - $994

2020 2 penalties totaling $10,173

$9,750
Fine
June 17, 2020
$423
Fine
June 8, 2020
Average: $5,087 | Range: $423 - $9,750

Fire Safety Deficiencies

Unknown Date

No description available

Inspection Survey Reports

Health

April 12, 2023
0.00

Health

September 9, 2021
0.00

Health

January 9, 2020
0.00

Quality Measures

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Short Stay

Quality Measure

Short Stay

Quality Measure

Short Stay

Quality Measure

Short Stay

Quality Measure

Short Stay

Quality Measure

Long Stay

Quality Measure

Long Stay

Quality Measure

Short Stay

Ownership Information

For profit - Corporation
Independent (Not part of a chain)
495389
495389
5406677830
Frederick

Historical Ownership Records

August 25, 2025
Organization
August 25, 2025
Organization
August 25, 2025
Organization