Federal inspection record · CMS data as of October 1, 2026
The Laurels Of Willow Creek
11611 Robious Road, Midlothian, VA · (804) 379-4771
- Certified beds
- 120
- Residents per day
- 99
- Ownership
- For-Profit
- Chain
- Ciena Healthcare/Laurel Health Care
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 24, 1991
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Virginia.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Virginia homes
The Laurels Of Willow Creek carries 111 inspection points. That is fewer than 30% of Virginia's 287 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Virginia: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–16 pts
- 4★ 16–45 pts
- 3★ 45–76.5 pts
- 2★ 76.5–168.75 pts
- 1★ over 168.75 pts
Bars show every rated home in Virginia by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
54 health citations on record since 2019. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Ensure that residents are free from significant medication errors.
Everything else, by area of care
Resident Assessment and Care Planning14E
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure each resident receives an accurate assessment.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care12E
- E
Provide safe, appropriate pain management for a resident who requires such services.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
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.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Resident Rights9E
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- E
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.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
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.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Nutrition and Dietary5F
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Pharmacy Service3E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Nursing and Physician Services3D
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- C
Post nurse staffing information every day.
- D
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.
Freedom from Abuse, Neglect, and Exploitation3D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Environmental1D
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Administration1D
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Infection Control1D
- D
Provide and implement an infection prevention and control program.
Inspection history
2023-09-13
18 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2022-03-24
17 health deficiencies · 2 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2019-03-14
19 health deficiencies · 10 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 41 min of nursing staff time a day, 35 min of it from a registered nurse.
This home
3 h 41 min
Virginia average
3 h 53 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 47% of nursing staff and 25% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.1 pts better | 1.3 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.7 pts better | 0.7 | 1.4 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.8 pts better | 93.0% | 91.2% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.1 pts worse | 89.2% | 93.3% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.3 pts better | 2.2% | 3.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms19.3 pts better | 1.2% | 20.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight4.9 pts worse | 10.2% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication1.7 pts better | 19.0% | 20.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.6 pts better | 10.6% | 14.2% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.5 pts worse | 14.7% | 14.2% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased4.3 pts better | 10.2% | 14.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.2 pts worse | 0.6% | 0.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.6 pts better | 0.0% | 1.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence10.1 pts worse | 31.4% | 21.3% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.8 pts worse | 8.2% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine4.1 pts worse | 70.1% | 74.2% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4.9 pts better | 6.6% | 11.5% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.2 pts worse | 1.5% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine5 pts better | 78.3% | 73.3% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.7 pts better | 20.3% | 22.0% | 23.4% |
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Fire safety
17 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke7E
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
- D
Have properly sized and located compartments to protect residents from smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- C
Provide properly protected cooking facilities.
Gas, Vacuum, and Electrical Systems4D
- D
Have proper power supply for life support equipment.
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- D
Ensure proper usage of power strips and extension cords.
- B
Meet requirements for the use of electrical equipment.
Egress3E
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D
Meet other general requirements that are deficient.
- E
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.
Construction1F
- F
Use approved construction type or materials.
Services1F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous1B
- B
Provide a written emergency evacuation plan.
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Other homes nearby
-
The Laurels Of Bon Air
Bon Air, VA · Ciena Healthcare/Laurel Health Care
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 44 min
- Fines
- $0
-
Southampton Rehabilitation And Healthcare Center
Richmond, VA · Marquis Health Services
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 14 min
- Fines
- $36,283
-
The Haven At Brandermill Woods
Midlothian, VA
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 5 min
- Fines
- $0