Facility WatchInspection records for every certified US nursing home
THE Laurels of Willow Creek
11611 Robious Road Midlothian, VA 23113 (804) 379-4771
CCN
495257
Certified beds
120
Ownership
For profit - Corporation
Chain
Ciena Healthcare/laurel Health Care
Nurse staffing
3.60
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.48 hours per resident per day
Nursing staff turnover: 45% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected September 13, 2023
18 citations · from a complaint investigation · Health
C
F0732No actual harm with potential for minimal harm · Widespread
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0585No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0676No actual harm with potential for more than minimal harm · Isolated
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0700No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0725No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0800No actual harm with potential for more than minimal harm · Isolated
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Deficient, Provider has date of correction · corrected October 16, 2023
D
F0812No actual harm with potential for more than minimal harm · Isolated
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected October 16, 2023
E
F0656No actual harm with potential for more than minimal harm · Pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected October 16, 2023
E
F0697No actual harm with potential for more than minimal harm · Pattern
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected October 16, 2023
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected October 16, 2023
E
F0757No actual harm with potential for more than minimal harm · Pattern
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected October 16, 2023
Inspected March 24, 2022
17 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0561No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0645No actual harm with potential for more than minimal harm · Isolated
PASARR screening for Mental disorders or Intellectual Disabilities
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0657No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected April 19, 2022
D
F0909No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected April 19, 2022
E
F0656No actual harm with potential for more than minimal harm · Pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected June 2, 2022
E
F0658No actual harm with potential for more than minimal harm · Pattern
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected June 2, 2022
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected April 19, 2022
E
F0842No actual harm with potential for more than minimal harm · Pattern
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 19, 2022
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected June 2, 2022
G
F0684Actual harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected June 2, 2022
G
F0760Actual harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected April 19, 2022
Inspected March 14, 2019
19 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0622No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0657No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0690No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0727No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0770No actual harm with potential for more than minimal harm · Isolated
Provide timely, quality laboratory services/tests to meet the needs of residents.
Deficient, Provider has date of correction · corrected April 26, 2019
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 26, 2019
E
F0584No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected April 26, 2019
E
F0695No actual harm with potential for more than minimal harm · Pattern
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 26, 2019
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 26, 2019