Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
THE LAURELS OF WILLOW CREEK
MIDLOTHIAN, VA · 120 certified beds · Last Life Safety survey September 13, 2023
CMS Certification Number 495257 · first certified September 1991
Ownership
Operated by CIENA HEALTHCARE/LAUREL HEALTH CARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within VA
17 citations — more than 74% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: April 2026 to April 2027. This facility’s last Life Safety survey was September 2023. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index
- F-0909 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.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 17 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 14, 2019 | 10 |
| March 24, 2022 | 2 |
| September 13, 2023 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2019-03-14 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2023-09-13 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2019-03-14 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2022-03-24 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2019-03-14 |
| K-0161 | Use approved construction type or materials. | 1 | 2019-03-14 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2019-03-14 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-09-13 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 3
- Miscellaneous Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 13, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 8, 2023) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (November 8, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 8, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 8, 2023) |
| K-0371 | Have properly sized and located compartments to protect residents from smoke. | Deficient, Provider has date of correction (November 8, 2023) |
March 24, 2022 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0915 | Have proper power supply for life support equipment. | Deficient, Provider has date of correction (May 10, 2022) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (May 10, 2022) |
March 14, 2019 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0222 | 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. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (May 22, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 22, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.