Cycle 1
Health 2023-09-13 · Fire 2023-09-13
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Midlothian, VA
The Laurels Of Willow Creek
2-star overall rating with 2-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
11611 Robious Road, Midlothian, VA
(804) 379-4771
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1991-09-24
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
0.41
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,001
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9947
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.41
Baseline 16.86% · Performance 17.54% · Measure score 8.41 · Achievement 8.41 · Improvement 0
Healthcare-associated infections
3.74
Baseline 6.57% · Performance 6.72% · Measure score 3.74 · Achievement 3.74 · Improvement 0
Total nurse turnover
3.96
Baseline 58.95% · Performance 47.48% · Measure score 3.96 · Achievement 3.96 · Improvement 2.86
Adjusted total nurse staffing
0.61
Baseline 3.20 hours · Performance 3.25 hours · Measure score 0.61 · Achievement 0.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 422 · Observed rate 8.77% · Lower 95% interval 7.59% |
| Discharge to community | 54.79% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 430 · Observed rate 51.4% · Lower 95% interval 50.45% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.14% |
95.27%
0.1 pts worse
|
Numerator 235 · Denominator 247 |
| Falls with major injury | 1.21% |
0.77%
0.4 pts worse
|
Numerator 3 · Denominator 247 |
| Discharge self-care score | 61.8% |
53.69%
8.1 pts better
|
Numerator 110 · Denominator 178 |
| Discharge mobility score | 67.98% |
50.94%
17 pts better
|
Numerator 121 · Denominator 178 |
| Pressure ulcers or injuries, new or worsened | 2.43% |
2.29%
0.1 pts worse
|
Numerator 6 · Denominator 247 · Adjusted rate 2.32% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 263 · Observed rate 6.08% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 182 |
| Staff flu vaccination coverage | 8.98% |
42%
33 pts worse
|
Numerator 30 · Denominator 334 |
| Discharge function score | 70.22% |
56.45%
13.8 pts better
|
Numerator 125 · Denominator 178 |
| Transfer of health information to provider | 99.46% |
95.95%
3.5 pts better
|
Numerator 183 · Denominator 184 |
| Transfer of health information to patient | 97.78% |
96.28%
1.5 pts better
|
Numerator 44 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 50 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
91.2%
1.6 pts better
|
93.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 90.9% · Q3 92.0% · Q4 93.4% · 4Q avg 92.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.7% · Q4 2.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
15.7%
14.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 4.2% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.7%
2.2 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.4% · Q3 9.7% · Q4 12.5% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
20.2%
1.2 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 21.9% · Q3 23.3% · Q4 20.0% · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
15.0%
1.7 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 13.8% · Q3 12.5% · Q4 12.9% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 19.5% |
17.5%
2 pts worse
|
16.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 19.2% · Q4 12.2% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
15.7%
4.3 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.9% · Q3 10.6% · Q4 11.1% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 0.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
22.2%
0.9 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 25.2% · Q3 28.5% · Q4 24.0% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.2%
3.5 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.2% · Q3 9.2% · Q4 11.5% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.7% |
74.6%
4.1 pts better
|
81.7%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.1% · Q2 86.2% · Q3 80.3% · Q4 65.2% · 4Q avg 78.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
11.7%
0.9 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.0% · Expected 10.3% · 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 1.0% · Q2 1.1% · Q3 2.5% · Q4 2.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.5% |
73.6%
14.9 pts better
|
79.7%
8.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
22.0%
3.3 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 23.4% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-24 · Fire 2022-03-24
17 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-03-14 · Fire 2019-03-14
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-13
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 2023-11-08
D · Potential for more than minimal harm
2023-09-13
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-13
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-11-08
D · Potential for more than minimal harm
2022-03-24
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-05-10
D · Potential for more than minimal harm
2022-03-24
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-05-10
F · Potential for more than minimal harm
2019-03-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-05-22
F · Potential for more than minimal harm
2019-03-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-05-22
E · Potential for more than minimal harm
2019-03-14
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 2019-05-22
E · Potential for more than minimal harm
2019-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-03-14
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 2019-05-22
D · Potential for more than minimal harm
2019-03-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-03-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-22
C · Minimal harm
2019-03-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-05-22
B · Minimal harm
2019-03-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-05-22
B · Minimal harm
2019-03-14
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-05-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-09-13
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 2023-10-16
E · Potential for more than minimal harm
2023-09-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-13
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 2023-10-16
E · Potential for more than minimal harm
2023-09-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
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 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F700 · Quality of Life and Care Deficiencies
Health
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 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-16
C · Minimal harm
2023-09-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-16
G · Actual harm
2022-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-02
G · Actual harm
2022-03-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-04-19
F · Potential for more than minimal harm
2022-03-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-02
E · Potential for more than minimal harm
2022-03-24
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 2022-06-02
E · Potential for more than minimal harm
2022-03-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-02
E · Potential for more than minimal harm
2022-03-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-24
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 2022-04-19
D · Potential for more than minimal harm
2022-03-24
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 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-24
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 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-24
F909 · Environmental Deficiencies
Health
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.
Corrected 2022-04-19
E · Potential for more than minimal harm
2019-03-14
F584 · Resident Rights Deficiencies
Health
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 2019-04-26
E · Potential for more than minimal harm
2019-03-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-04-26
E · Potential for more than minimal harm
2019-03-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F622 · Resident Rights Deficiencies
Health
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F727 · Nursing and Physician Services Deficiencies
Health
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-26
Penalties and ownership
What sits behind the stars
Ownership
Laurel Health Care Holdings, Inc.
5% Or Greater Direct Ownership Interest · Organization
Felty, Danny
Operational/Managerial Control · Individual
Khan, Anis
Operational/Managerial Control · Individual
Khan, Anis
Corporate Officer · Individual
Laurel Acquisition Holding Corporation
5% Or Greater Indirect Ownership Interest · Organization
Laurel Health Care Company
Operational/Managerial Control · Organization
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
Qazi, Mohammad
Corporate Director · Individual
Qazi, Mohammad
Corporate Officer · Individual
Shive, Stacie
Operational/Managerial Control · Individual
Stobb, David
Corporate Officer · Individual
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The Laurels Of Bon Air
Bon Air, VA
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Southampton Rehabilitation And Healthcare Center
Richmond, VA
2-star overall rating with 2-star inspections with $38,952 in total fines with 20 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Haven At Brandermill Woods
Midlothian, VA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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