This article is the first in a two-part investigative series about Envoy of Williamsburg. Read the second part of the series here.
The street was quiet as a gentle June breeze rustled tree branches shading Mount Vernon Avenue in Williamsburg.
Clad in eggshell-white paint and capped with a flat gray roof, the nursing home stretched a few hundred feet down the road, glossy windows reflecting the clear blue sky above. Save for a few flashes of movement behind the large-pane windows, drawn Venetian blinds obscured much of the building’s interior.
As air conditioners hummed outside, a car pulled up in front of the nursing home near a royal blue sign reading “ENVOY of WILLIAMSBURG — Skilled Nursing and Rehabilitation Center.”
For Andrea Clarke, a former medical-transport company employee, memories of the nursing home do not match the building’s unassuming exterior.
When Clarke looks at Envoy of Williamsburg, a Medicaid- and Medicare-approved facility at 1235 Mount Vernon Ave., she thinks of the elderly woman who nearly died in Clarke’s ambulance while being transported to a dialysis appointment.
“To be perfectly blunt, it’s one of the outer circles of hell,” Clarke said.
“Its people you’re talking about,” she added.
A ‘pervasive odor’
Envoy of Williamsburg, formerly known as Ruxton Health of Williamsburg, has left a trail of citations resulting from health department inspections and a slew of emergency calls throughout the past decade.
The most recent federal inspection report available details a patient-on-patient sexual assault, staff members failing to update a resident’s doctor on health changes, rusty vent covers and a “pervasive odor throughout the facility.”
A Freedom of Information Act request by WYDaily also shows that, out of all Medicare- and Medicaid-funded nursing homes in Williamsburg and James City County, Envoy had the most emergency police and fire calls per bed over the past five years.
Further, Nursing Home Compare, a federal database on the official U.S. government website for Medicare, now rates Envoy one out of of five stars in multiple categories. Of six nursing homes in the Williamsburg area that accept Medicare and Medicaid funding, Envoy has the poorest scores — one out of five stars — in both its overall rating and health inspections.
The facility has two stars for staffing and quality measures.
A nursing home administrator at Envoy did not return a request for comment.
A 2017 report
When Clarke walked in to Envoy of Williamsburg, the first thing that struck her was the smell.
The odor was not like that of other nursing homes Clarke had encountered — it smelled of unwashed humans and dirty carpet, she said. Clarke, who worked for a medical-transport company through 2015 and 2016, said she had seen comparable nursing homes in eastern Virginia, but none in Williamsburg.
A March 2017 inspection by the Centers for Medicare and Medicaid Services said Envoy had 16 health citations. During that period, Virginia nursing homes averaged 8.1 citations, and nursing homes nationwide averaged 5.8. The U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services inspect nursing homes annually to ensure the homes are meeting regulations and investigate any complaints.
The 2017 report documents several health deficiencies at Envoy, including improper tracking of patients’ medications, giving additional and unnecessary medications to a patient, unsafe food- preparation methods, sexual assault, biohazards and more.
The list of deficiencies begins with details of a sexual assault between two patients, which inspectors say staff failed to prevent. Inspectors discovered that a certified nursing assistant left the room as the assault was occurring to “tell the nurses.”
The report does not detail if the CNA faced any repercussions, but does state staff also “failed to protect one resident … from another resident after a sexual assault.”
A police officer was called to the nursing home for the incident, but the report does not specify if any charges were filed.
Another section of the health inspection report states staff failed to keep the biohazardous waste closet, which contained used syringes and other waste, closed and locked.
“The closet had a strong, foul human waste odor, which could be detected in the hallway outside of the room,” the report reads.
Envoy has been fined for citations twice in the past three years: once on April 17, 2015, for $68,250, and again on June 24, 2016, for $131,286.
On those dates, the federal government also withheld Medicare funding to the nursing home until the citations were corrected.
Beyond the health inspections, emergency responders also are called to to Envoy more often than any other area nursing home, according to data from city and county officials.
In March, WYDaily submitted a Freedom of Information Act request to both James City County and York County officials, requesting total annual call numbers since 2013.
The request covered 130-bed Envoy of Williamsburg, 90-bed Consulate Health Care of Williamsburg, 80-bed York Convalescent Center and 60-bed Convalescent Center at Patriots Colony.
Both Envoy and Consulate Health Care of Williamsburg are operated by Consulate Health Care.
The data show Envoy has the most police and fire emergency calls per bed of any nursing home with at least 60 beds in the area.
Envoy consistently netted more than two calls per bed each year. Other facilities consistently were under 1.7 calls per bed each year.
“You wouldn’t want to treat your mom or grandma that way. Nobody deserves to be treated this way,” Clarke said.
Do you have an experience with Envoy or another Williamsburg-area nursing home you’d like to share? Get in touch with us at email@example.com.