Cycle 1
Health 2025-09-09 · Fire 2022-09-19
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
West Carrollton, OH
Laurels Of West Carrollton The
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
115 Elmwood Circle, West Carrollton, OH
(937) 866-3814
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1983-05-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
84 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,736
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.81
Baseline 22.09% · Performance 20.92% · Measure score 1.81 · Achievement 1.10 · Improvement 1.81
Healthcare-associated infections
0
Baseline 7.78% · Performance 8.36% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.79
Baseline 71.05% · Performance 60.49% · Measure score 1.79 · Achievement 0.78 · Improvement 1.79
Adjusted total nurse staffing
2.60
Baseline 2.99 hours · Performance 3.82 hours · Measure score 2.60 · Achievement 2.60 · Improvement 2.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.33% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 15.38% · Lower 95% interval 7.94% |
| Discharge to community | 56.32% |
50.57%
5.8 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 48.72% · Lower 95% interval 43% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 6 · Denominator 24 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 8 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.36% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 9.01% |
8.2%
0.8 pts better
|
Numerator 10 · Denominator 111 |
| Staff flu vaccination coverage | 10.83% |
42%
31.2 pts worse
|
Numerator 17 · Denominator 157 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 8 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
92.4%
3.3 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.8% · Q2 95.2% · Q3 95.2% · Q4 100.0% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
94.5%
1.3 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.3%
0.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.6% · Q3 3.2% · Q4 1.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
26.1%
21.8 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 14.3% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 19.8% |
6.2%
13.6 pts worse
|
5.4%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 8.8% · Q3 23.6% · Q4 23.5% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.3% |
25.4%
2.9 pts worse
|
19.6%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 26.3% · Q3 32.7% · Q4 28.8% · 4Q avg 28.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
11.5%
7.1 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 2.7% · Q3 0.0% · Q4 2.6% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.8% |
7.7%
5.1 pts worse
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 15.6% · Q3 3.9% · Q4 8.2% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
6.2%
0.5 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 7.1% · Q3 1.9% · Q4 2.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.2%
0.1 pts worse
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.5%
0.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.2% |
21.7%
9.5 pts worse
|
19.8%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 47.4% · Q3 28.7% · Q4 21.4% · 4Q avg 31.2% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
3.7%
0.7 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.8% · Q3 5.5% · Q4 2.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
78.1%
13.8 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 91.9% · Q3 92.9% · Q4 91.0% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
12.5%
3.5 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 18.5% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
75.6%
12.5 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.9% |
25.1%
8.8 pts worse
|
23.9%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.9% · Observed 44.4% · Expected 31.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-19 · Fire 2019-09-19
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-09-19 · Fire 2018-08-02
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-09-19
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-19
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-10-21
F · Potential for more than minimal harm
2019-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-24
F · Potential for more than minimal harm
2018-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-09-13
E · Potential for more than minimal harm
2018-08-02
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-09-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-12-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-09-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F690 · Quality of Life and Care Deficiencies
Health
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 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-09-09
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-11-01
D · Potential for more than minimal harm
2024-12-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-04-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-03
D · Potential for more than minimal harm
2023-08-02
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-06-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-18
F · Potential for more than minimal harm
2022-09-19
F761 · Pharmacy Service Deficiencies
Health
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 2022-10-21
F · Potential for more than minimal harm
2022-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-21
F · Potential for more than minimal harm
2019-09-19
F761 · Pharmacy Service Deficiencies
Health
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 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F690 · Quality of Life and Care Deficiencies
Health
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 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-10-24
Penalties and ownership
What sits behind the stars
Ownership
Laurel Health Care Holdings, Inc.
5% Or Greater Direct Ownership Interest · Organization
Khan, Anis
Operational/Managerial Control · Individual
Laurel Acquisition Holding Corporation
5% Or Greater Indirect Ownership Interest · Organization
Laurel Health Care Company
Operational/Managerial Control · Organization
Modgil, Parminder
Operational/Managerial Control · Individual
Mohammad A Qazi Living Trust Dated 09/26/97
5% Or Greater Indirect Ownership Interest · Organization
Qazi, Mohammad
5% Or Greater Indirect Ownership Interest · Individual
Qazi, Mohammad
Operational/Managerial Control · Individual
Schoenlein, Stephanie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Sycamorespring Of Miamisburg
Miamisburg, OH
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Wood Glen Alzheimer's Community
Dayton, OH
2-star overall rating with 3-star inspections with 12 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Vienna Springs Health Campus
Dayton, OH
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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