C75

THE LAURELS OF WILLOW CREEK

Grade C 75/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
4/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

120

Ownership

For profit - Corporation

Total Fines

None

Last Survey

N/A

11611 ROBIOUS ROAD, MIDLOTHIAN, VA 23113
8043794771

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.46h
LPN
1.00h
CNA
2.17h
Total
3.62h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

LAUREL HEALTH CARE HOLDINGS, INC.

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Feb 2016

100%

LAUREL ACQUISITION HOLDING CORPORATION

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2016

MOHAMMAD A QAZI LIVING TRUST DATED 09/26/97

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2016

QAZI, MOHAMMAD

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2016

LAUREL HEALTH CARE COMPANY

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2016

FELTY, DANNY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

KHAN, ANIS

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2016

QAZI, MOHAMMAD

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2016

SHIVE, STACIE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2021

QAZI, MOHAMMAD

IndividualCORPORATE DIRECTORSince Feb 2016

KHAN, ANIS

IndividualCORPORATE OFFICERSince Feb 2016

QAZI, MOHAMMAD

IndividualCORPORATE OFFICERSince Feb 2016

STOBB, DAVID

IndividualCORPORATE OFFICERSince Feb 2016

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (54)

September 13, 2023Health18 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Oct 16, 2023
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Oct 16, 2023
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 16, 2023
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 16, 2023
0676DMinimal harm, Isolated

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Corrected Oct 16, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Oct 16, 2023
0697EMinimal harm, Pattern

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Oct 16, 2023
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Oct 16, 2023
0700DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Oct 16, 2023
0725DMinimal harm, Isolated

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Oct 16, 2023
0732CNo harm, Widespread

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Oct 16, 2023
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 16, 2023
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Oct 16, 2023
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 16, 2023
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Oct 16, 2023
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 16, 2023
0757EMinimal harm, Pattern

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Oct 16, 2023
0800DMinimal harm, Isolated

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Nutrition and Dietary Deficiencies

Corrected Oct 16, 2023
March 24, 2022Health17 deficiencies2 severe
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Apr 19, 2022
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Apr 19, 2022
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2022
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2022
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2022
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 2, 2022
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2022
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 2, 2022
0684GActual harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jun 2, 2022
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2022
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Apr 19, 2022
0760GActual harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 19, 2022
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Apr 19, 2022
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jun 2, 2022
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2022
0909DMinimal harm, Isolated

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.

Environmental Deficiencies

Corrected Apr 19, 2022
March 14, 2019Health19 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Apr 26, 2019
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Apr 26, 2019
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 26, 2019
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 26, 2019
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 26, 2019
0622DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Apr 26, 2019
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Apr 26, 2019
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Apr 26, 2019
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 26, 2019
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 26, 2019
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 26, 2019
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Apr 26, 2019
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 26, 2019
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Apr 26, 2019
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 26, 2019
0727DMinimal harm, Isolated

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.

Nursing and Physician Services Deficiencies

Corrected Apr 26, 2019
0770DMinimal harm, Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Corrected Apr 26, 2019
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Apr 26, 2019
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 26, 2019

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Frequently Asked Questions

What is the CareGrader rating for THE LAURELS OF WILLOW CREEK?

THE LAURELS OF WILLOW CREEK in MIDLOTHIAN, Virginia has a CareGrader grade of C (Average), with a composite score of 75.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for THE LAURELS OF WILLOW CREEK?

THE LAURELS OF WILLOW CREEK has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does THE LAURELS OF WILLOW CREEK have?

THE LAURELS OF WILLOW CREEK has 54 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does THE LAURELS OF WILLOW CREEK have?

THE LAURELS OF WILLOW CREEK has 120 certified beds with approximately 114 current residents (95% occupancy). The facility is located at 11611 ROBIOUS ROAD, MIDLOTHIAN, Virginia 23113. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.