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The Laurels of Willow Creek

11611 Robious Road, Midlothian, VA 23113 · Chesterfield County · (804) 379-4771

120 certified beds, about 112 residents a day · For profit - Corporation · Medicare and Medicaid since 1991

Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
3 of 5
Quality measures
4 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 495257 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on September 13, 2023, inspectors cited 18 health deficiencies (the Virginia average is 14.3, the national average 9.2).

Of 54 health citations since March 2019, 2 were rated as actual harm or immediate jeopardy to residents.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.24 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.50 of those hours.

47.0% of nursing staff left within the year CMS measured (Virginia average 48.1%).

CMS links it to Ciena Healthcare/Laurel Health Care, an affiliated group of 81 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 54 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
39D
11E
1F
Potential for minimal harm
0A
0B
1C
September 13, 2023Standard inspection, Complaint inspection · 18 citations
  1. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 37 residents in the survey sample; Residents #100, #88, #91, #87, and #7.
  2. E
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wrote2. For R7 the facility staff failed to identify the location of the pain, the type of pain and attempts of non-pharmacological interventions prior to the administration of a prn (as needed) pain medication, Tramadol (1). R7 was admitted with diagnosis that included but not limited to osteoarthritis (2) of the knee. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R7 was cognitively intact for making daily decisions. Section J Pain Management coded R7 as having frequent pain at a pain level of six out of ten, with ten being the worse pain. R7's comprehensive care plan dated 02/22/2022 documented in part, Need. [...]
  3. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 37 residents in the survey sample, Resident #310.
  4. E
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure residents were free from unnecessary medications for four of 37 residents in the survey sample; Residents #100, #88, #91, and #7.
  5. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to promote dignity for one of 37 residents, Resident #24.
  6. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician medications not ordered and/or administered, for two of 37 residents in the survey sample, Resident #225 and Resident #87.
  7. 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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promptly resolve a grievance for one of 37 residents in the survey sample, Resident #87.
  8. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 37 residents, Resident #103.
  9. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for three of 37 residents in the survey sample, Residents #87, #55 and #225.
  10. D
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    F676 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) for one of 37 residents, Resident #24.
  11. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for the treatment of pressure injuries for one of 37 residents in the survey sample; Resident #205.
  12. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services in a sanitary manner for one of 37 residents in the survey sample, Residents #21.
  13. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence communication with the dialysis center for each dialysis visit for one of two residents in the survey sample that received dialysis services; Resident #91.
  14. 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.
    F700 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure all bed rail requirements were met for one of 37 residents in the survey sample, Resident #87.
  15. D
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to ensure a resident's needs were met for one of 37 residents in the survey sample, Resident #24.
  16. D
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    F800 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide a diet to meet a resident's needs for one of 37 residents in the survey sample, Resident #310.
  17. D
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens.
  18. C
    Post nurse staffing information every day.
    F732 · Nursing and Physician Services · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) October 16, 2023
    Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift on two of three survey dates.
March 24, 2022Standard inspection · 17 citations
  1. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) June 2, 2022
    Inspectors wrote2. The facility staff failed to administer the correct physician prescribed dose of the Pfizer COVID-19 vaccine to Resident #317 (R317). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/20/21, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. A review of R317's clinical record revealed a physician's order dated 12/16/21 for 0.3 ml (milliliters) of the Pfizer COVID-19 vaccine. A medication error report dated 12/16/21 documented R317 was administered 1.8 ml of the Pfizer vaccine. The report further documented the physician was notified, ordered intravenous normal saline at 50 ml per hour for one hour and R317 had no adverse outcome. [...]
  2. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on resident interview, clinical record review, facility document review, and staff interview, it was determined that the facility staff failed to ensure a resident was free of a significant medication error for one of 51 residents in the survey sample, Resident #16 (R16). On 11/02/2021 at 10:00 p.m. and on 11/03/2021at 6:00 a.m., facility staff overdosed Resident # 16 R16 by administering 5ml (five milliliters) of Methadone (1), which was ten times the physician ordered dose, resulting in (R16's) oxygen saturation dropping to 77% and requiring administration of Narcan (2). The resident was taken to the hospital for further interventions and monitoring. The deficient practice resulted in harm to the resident.
  3. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) June 2, 2022
    Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens.
  4. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 2, 2022
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement a comprehensive care plan for 5 of 51 residents in the survey sample; Residents #216, #217, #112, and #16.
  5. E
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 2, 2022
    Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 1 of 51 residents in the survey sample; Resident #80. The facility staff failed to clarify physician's orders regarding parameters for the administration of PRN (as-needed) pain medication for Resident #80.
  6. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to prepare food in a manner that was palatable for meal enjoyment.
  7. E
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a complete and accurate medical record for three of 51 residents in the survey sample, Resident #112, Resident #416 and Resident #3.
  8. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide privacy and dignity to 1 of 51 residents in the survey sample, Resident #216. The facility staff failed to maintain the Foley catheter bag in a manner to promote privacy and dignity for Resident #216.
  9. D
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    F561 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observation, resident interview, facility document review and clinical record review, it was determined that the facility staff failed to facilitate a resident's right for self-determination and choice for 1 of 51 residents in the survey sample, Resident #313. Resident #313 (R313) verbalized the desire for bed rails. The facility staff failed to honor this preference and assess the resident for the use of bed rails.
  10. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 51 residents in the survey sample, Resident #35. The facility staff failed to complete the BIMS (brief interview for mental status) assessment for Resident #35's (R35) quarterly MDS assessment with an ARD (assessment reference date) of 1/14/22.
  11. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 1 of 51 residents, Resident #62. The facility staff failed to complete a level 1 PASRR for Resident #62 who was admitted to the facility on [DATE].
  12. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for 1 of 51 residents in the survey sample, Resident #316. The facility staff failed to develop Resident #316's (R316) baseline care plan to include the use of oxygen.
  13. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the care plan for two of 51 residents in the survey sample, Residents #53 and #216.
  14. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observation, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide treatment to promote healing of a pressure injury for 1 of 51 residents in the survey sample, Resident #3. The facility staff failed to follow professional standards of care when providing treatment to Resident #3's pressure injury on 3/23/2022. LPN (licensed practical nurse) #1 was observed using one piece of gauze to clean off three separate pressure injuries located on Resident #3.
  15. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide respiratory services for three of 51 residents in the survey sample, Residents #1, #316 and #16.
  16. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to prevent a resident from receiving an unnecessary medication for one five residents in the medication administration observation, Resident #9. The facility staffadministered a double dose of nasal spray to Resident #9.
  17. 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.
    F909 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 19, 2022
    Inspectors wroteBased on observations, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed inspection was provided for one of 51 residents in the survey sample, Resident #412. The facility staff failed to perform bed rail inspections for the use of positioning/assist bars for Resident #412.
March 14, 2019Standard inspection · 19 citations
  1. 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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on observation, resident interview, staff interview, family interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to maintain and clean, comfortable, homelike environment for two of 53 residents in the survey sample, Residents #20 and #92 and for 74 of 78 resident rooms. 1. The facility staff failed to clean and store a bedpan in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall in Resident #20's bathroom. 2. The facility staff failed to maintain Resident #92's bathroom in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall. 3. [...]
  2. E
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services consistent with professional standards of practice for four of 53 residents in the survey sample, Residents # 9, # 104, # 55, and # 23. 1. The facility staff failed to store Resident # 9's BI-PAP [bi-level positive air pressure] (1) mask and tubing in a sanitary manner. During multiple observations of Resident 9's BI-PAP mask and tubing, revealed the mask was stored uncovered and not in a bag. 2. The facility staff failed to administer Resident #104's oxygen according to physician's orders. 3. The facility staff failed to administer Resident #55's oxygen according to the physician's order. 4. The facility staff failed to store Resident #23's respiratory equipment in a sanitary manner.
  3. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on observation and staff interview, the facility staff failed to prepare and serve food in a sanitary manner in the kitchen. A dietary aide failed to secure their hair properly in a hair net, failed to wash their hands before beginning food preparation, and touched the eating surface of food plates with un-gloved hands.
  4. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to serve food in a manner to promote resident dignity for one of 53 residents in the survey sample, Resident # 264. The facility staff failed to serve food in a manner to promote dignity in the facility's main dining room. Resident # 264 waited twenty-two minutes to receive her lunch meal, after her tablemate was served and eating the lunch meal.
  5. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for two of 53 residents in the survey sample, Residents #87 and #89. 1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to implement the abuse policy for reporting and completing a thorough investigation of the allegation. 2. The facility staff failed to implement the abuse policy for reporting a resident-to-resident altercation when Resident # 89 received a scratch under their eye on 12/07/18.
  6. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report allegations of abuse within the required time frame for two of 53 residents in the survey sample, Residents #87 and #89. 1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to report this allegation to the state agency and other agencies according to law. 2. The facility staff failed to ensure timely reporting to the State Agency and other officials in accordance with state law when Resident # 89 received a scratch under their eye on 12/07/18 during a resident to resident altercation. The incident was not reported until 12/10/18.
  7. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to complete a thorough abuse investigation for one of 53 residents in the survey sample, Resident #87. On 2/14/19, Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to conduct a complete and thorough investigation regarding this allegation.
  8. 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.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence that all required information, including comprehensive care plan goals, was provided to the receiving hospital when one of 53 residents in the survey sample, Resident #20, was transferred to the hospital on [DATE] and 12/24/18. The facility staff failed to provide the receiving hospital with the Resident #20's comprehensive care plan goals during a facility initiated transfer to the hospital on [DATE] and 12/24/18.
  9. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview and clinical record review, it was determined the facility staff failed to provide written notification to the resident and/or resident representative and/or ombudsman of a facility initiated transfer for two for 53 residents in the survey sample, Residents #20 and #50. 1. The facility staff failed to provide written notification to Resident #20 or the responsible representative for the 12/17/18 and 12/24/18 facility initiated transfers to the hospital. 2. The facility staff failed to provide evidence that the Ombudsman was provided written notification of Resident #50's facility initiated transfer to the hospital on 1/14/19.
  10. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that facility staff failed to update a baseline care plan for one of 53 residents in the survey sample, Resident # 53. The facility staff failed to update Resident # 53's baseline care plan concerning a fall on 02/11/19.
  11. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 53 residents in the survey sample, Residents #36, and #50. 1. The facility staff failed to develop a care plan to address Resident #36's urinary incontinence. 2. The facility staff failed to develop a comprehensive care plan to include Resident #50's risk for altered nutritional status based on the triggered Care Area Assessment (CAA) Summary - Nutritional Status from the Minimum Data Set (MDS) Section V dated 1/17/19.
  12. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for two of 53 residents in the survey sample, Resident # 53, and # 55. 1. The facility staff failed to update Resident # 53's comprehensive care plan concerning a fall on 02/15/19. 2. The facility staff failed to review and revise Resident #55's care plan to include oxygen administration.
  13. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for two of 53 residents in the survey sample, Residents #315 and #265. 1. The facility staff failed to clarify Resident #315's physician order regarding instruction for the removal of a lidocaine patch. 2. The facility staff failed to ensure that the physicians order for Resident # 265's prednisone (1) was transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018.
  14. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide the necessary services to maintain good grooming, and personal hygiene for one of 53 residents in the survey sample, Resident #315. The facility staff failed to provide a shower and/or bath from 7/30/18 through 8/13/18, to Resident #315, who was coded as requiring extensive assistance of one with Activities of daily living.
  15. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure two of 53 sampled residents, (Resident #92 and Resident #265), received treatment and care in accordance with professional standards of practice and the comprehensive care plan. 1. The facility staff failed to have blood work drawn according to the physician orders for Resident #92. 2. The facility staff failed to administer Resident # 265's was prednisone (1) as prescribed by the physician. Resident #265's prednisone was not transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018.
  16. 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.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on resident interview, family interview, facility document review and clinical record review, it was determined the facility staff failed to provide treatment and services to maintain or restore bladder and bowel function for one of 53 residents in the survey sample, Resident #92. The facility staff failed to implement a toileting plan to maintain or restore Resident #92's bladder and bowel function.
  17. 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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage. The facility staff failed to ensure eight consecutive hours of RN coverage for four days, 2/16/19, 3/2/19, 3/3/19 and 3/9/19.
  18. D
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    F770 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 53 residents in the survey sample, received the treatment and care in accordance with professional standards of practice and the comprehensive care plan for Resident #92. The facility staff failed to obtain physician ordered laboratory tests for Resident #92.
  19. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 26, 2019
    Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement infection control practices for one of 53 residents in the survey sample, and in the kitchen, Residents #164. The facility staff failed to ensure the implementation of contact isolation precautions for Resident #164.

Fire safety inspections

17 fire safety citations on file: 5 on September 13, 2023, 2 on March 24, 2022, 10 on March 14, 2019.

Every fire safety citation17 citations
  1. D
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · September 13, 2023 · Corrected (the home has a date of correction)
  2. D
    Meet other general requirements that are deficient.
    K 300 · September 13, 2023 · Corrected (the home has a date of correction)
  3. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · September 13, 2023 · Corrected (the home has a date of correction)
  4. D
    Install corridor and hallway doors that block smoke.
    K 363 · September 13, 2023 · Corrected (the home has a date of correction)
  5. D
    Have properly sized and located compartments to protect residents from smoke.
    K 371 · September 13, 2023 · Corrected (the home has a date of correction)
  6. D
    Have proper power supply for life support equipment.
    K 915 · March 24, 2022 · Corrected (the home has a date of correction)
  7. D
    Have a battery powered remote alarm panel in a location accessible by operating personnel.
    K 916 · March 24, 2022 · Corrected (the home has a date of correction)
  8. F
    Use approved construction type or materials.
    K 161 · March 14, 2019 · Corrected (the home has a date of correction)
  9. F
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · March 14, 2019 · Corrected (the home has a date of correction)
  10. 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.
    K 222 · March 14, 2019 · Corrected (the home has a date of correction)
  11. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · March 14, 2019 · Corrected (the home has a date of correction)
  12. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · March 14, 2019 · Corrected (the home has a date of correction)
  13. D
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · March 14, 2019 · Corrected (the home has a date of correction)
  14. D
    Ensure proper usage of power strips and extension cords.
    K 920 · March 14, 2019 · Corrected (the home has a date of correction)
  15. C
    Provide properly protected cooking facilities.
    K 324 · March 14, 2019 · Corrected (the home has a date of correction)
  16. B
    Provide a written emergency evacuation plan.
    K 711 · March 14, 2019 · Corrected (the home has a date of correction)
  17. B
    Meet requirements for the use of electrical equipment.
    K 919 · March 14, 2019 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeVirginiaUnited States
All nursing staff (RN, LPN and aides)3.243.763.86
Registered nurses0.500.690.69
All nursing staff on weekends2.793.293.42
Nurse aides1.90
Licensed practical nurses0.84
Nursing staff turnover (share who left in a year)47.0%48.1%45.8%
Registered nurse turnover33.3%48.2%42.9%
Administrators who left0

CMS expects 3.44 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.43 on weekdays and 2.79 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.34 in April to June 2025 to 3.24 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.240.503.432.79 0.0%0 of 90112
Oct to Dec 20253.340.443.522.86 0.1%0 of 92109
Jul to Sep 20253.220.413.352.88 0.0%0 of 92114
Apr to Jun 20253.340.333.532.86 0.0%0 of 91114
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Virginia, Jan to Mar 20263.580.563.763.125.7%0.2% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Virginia

JobMedianMiddle halfEmployed
Virginia, all employers
CNAs (nursing assistants)$20.77$17.80 to $22.5640,580
LPNs and LVNs$31.21$28.66 to $35.8415,550
Registered nurses$45.00$38.51 to $49.5377,490
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For The Laurels of Willow Creek. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
Employed by
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Do you get a shift differential?
Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeVirginiaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
9.814.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.40.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.01.61.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.53.63.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.81.31.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
13.815.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
9.14.74.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
11.214.215.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
23.422.323.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
7.911.512.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.11.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.11.51.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for The Laurels of Willow Creek's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

54.8% this home

No different from the national rate

US median of homes 51.5% · Virginia: 101 better, 22 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 430 eligible stays.

Potentially preventable readmissions

10.0% this home

No different from the national rate

US median of homes 10.7% · Virginia: 1 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 422 eligible stays.

Infections that led to a hospital stay

6.7% this home

No different from the national rate

US median of homes 7.1% · Virginia: 2 better, 8 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 263 eligible stays.

Self-care and mobility at discharge

64.6% this home

Median of homes: Virginia60.0% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 158 residents counted.

Falls with major injury

1.2% this home

Median of homes: Virginia0.7% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 246 residents counted.

New or worsened pressure ulcers

2.6% this home

Median of homes: Virginia2.1% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 246 residents counted.

Medication list given at discharge

98.2% this home

Median of homes: Virginia97.8% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 54 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: Legal Business Name Not Available. CMS links this home to Ciena Healthcare/Laurel Health Care, a group of 81 nursing homes averaging 2.8 stars overall.

NameRoleTypeShareSince
Ownership data not available

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. When is the care plan meeting, and can family attend it?Inspectors cited 14 problems in this area, most recently on September 13, 2023: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
  2. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 13 problems in this area, most recently on September 13, 2023: "Provide safe, appropriate pain management for a resident who requires such services."
  3. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 9 problems in this area, most recently on September 13, 2023: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
  4. Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 5 problems in this area, most recently on September 13, 2023: "Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.79 hours per resident per day, below the Virginia average of 3.29.

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Common questions

What is The Laurels of Willow Creek's Medicare star rating?
CMS rates The Laurels of Willow Creek 2 out of 5 stars overall, with 2 for health inspections, 3 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did The Laurels of Willow Creek get at its last inspection?
18 health deficiencies at the standard inspection on September 13, 2023. The Virginia average is 14.3.
Has The Laurels of Willow Creek been fined?
CMS lists no fines in the last three years.
Does The Laurels of Willow Creek accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns The Laurels of Willow Creek?
CMS lists 1 owner or manager, and links the home to Ciena Healthcare/Laurel Health Care. Legal business name: Legal Business Name Not Available.

Sources

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