Facility WatchInspection records for every certified US nursing home
Mountain Laurel Rehabilitation and Nursing
514 North Main Street Rural Retreat, VA 24368 (276) 686-7000
Special Focus Facility — SFF CandidateAbuse icon
CCN
495417
Certified beds
120
Ownership
For profit - Limited Liability company
Chain
Eastern Healthcare Group
Nurse staffing
3.31
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.43 hours per resident per day
Nursing staff turnover: 66% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 8, 2025
56 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 May 15, 2025
D
F0557No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected May 15, 2025
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 June 24, 2025
D
F0583No actual harm with potential for more than minimal harm · Isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected May 15, 2025
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 May 15, 2025
D
F0635No actual harm with potential for more than minimal harm · Isolated
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Deficient, Provider has date of correction · corrected May 15, 2025
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 May 15, 2025
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 May 15, 2025
D
F0661No actual harm with potential for more than minimal harm · Isolated
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected May 15, 2025
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 May 15, 2025
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected May 15, 2025
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 June 24, 2025
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 May 15, 2025
D
F0710No actual harm with potential for more than minimal harm · Isolated
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0711No actual harm with potential for more than minimal harm · Isolated
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0740No actual harm with potential for more than minimal harm · Isolated
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
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 June 24, 2025
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected May 15, 2025
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 June 24, 2025
D
F0758No actual harm with potential for more than minimal harm · Isolated
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0761No actual harm with potential for more than minimal harm · Isolated
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0773No actual harm with potential for more than minimal harm · Isolated
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0840No actual harm with potential for more than minimal harm · Isolated
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0841No actual harm with potential for more than minimal harm · Isolated
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Deficient, Provider has date of correction · corrected May 15, 2025
D
F0849No actual harm with potential for more than minimal harm · Isolated
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Deficient, Provider has date of correction · corrected May 15, 2025
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 June 24, 2025
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected May 15, 2025
E
F0565No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to organize and participate in resident/family groups in the facility.
Deficient, Provider has date of correction · corrected May 15, 2025
E
F0578No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Deficient, Provider has date of correction · corrected May 15, 2025
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 May 15, 2025
E
F0607No actual harm with potential for more than minimal harm · Pattern
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected May 15, 2025
E
F0623No actual harm with potential for more than minimal harm · Pattern
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 June 24, 2025
E
F0625No actual harm with potential for more than minimal harm · Pattern
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Deficient, Provider has date of correction · corrected May 15, 2025
E
F0655No actual harm with potential for more than minimal harm · Pattern
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 May 15, 2025
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 24, 2025
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 May 15, 2025
E
F0677No actual harm with potential for more than minimal harm · Pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected May 15, 2025
E
F0725No actual harm with potential for more than minimal harm · Pattern
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 May 15, 2025
E
F0770No actual harm with potential for more than minimal harm · Pattern
Provide timely, quality laboratory services/tests to meet the needs of residents.
Deficient, Provider has date of correction · corrected June 24, 2025
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 June 24, 2025
E
F0814No actual harm with potential for more than minimal harm · Pattern
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected May 15, 2025
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 June 24, 2025
E
F0865No actual harm with potential for more than minimal harm · Pattern
Have a plan that describes the process for conducting QAPI and QAA activities.
Deficient, Provider has date of correction · corrected May 15, 2025
E
F0944No actual harm with potential for more than minimal harm · Pattern
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Deficient, Provider has date of correction · corrected May 15, 2025
G
F0675Actual harm · Isolated
Honor each resident's preferences, choices, values and beliefs.
Deficient, Provider has date of correction · corrected May 15, 2025
G
F0690Actual 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 May 15, 2025
G
F0776Actual harm · Isolated
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Deficient, Provider has date of correction · corrected May 15, 2025
G
F0777Actual harm · Isolated
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Deficient, Provider has date of correction · corrected May 15, 2025
J
F0600Immediate jeopardy to resident health or safety · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected May 15, 2025
J
F0684Immediate jeopardy to resident health or safety · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected June 24, 2025
J
F0742Immediate jeopardy to resident health or safety · Isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Deficient, Provider has date of correction · corrected May 15, 2025
Inspected December 4, 2024
7 citations · from a complaint investigation · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected January 31, 2025
D
F0584No actual harm with potential for more than minimal harm · Isolated
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 January 31, 2025
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 January 31, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
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 January 31, 2025
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected January 23, 2025
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 January 31, 2025
G
F0697Actual harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected January 23, 2025
Inspected August 14, 2023
13 citations · from a complaint investigation · Health
D
F0602No actual harm with potential for more than minimal harm · Isolated
Protect each resident from the wrongful use of the resident's belongings or money.
Deficient, Provider has date of correction · corrected September 13, 2023
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 September 13, 2023
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 September 13, 2023
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 September 13, 2023
D
F0694No actual harm with potential for more than minimal harm · Isolated
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0710No actual harm with potential for more than minimal harm · Isolated
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Deficient, Provider has date of correction · corrected September 13, 2023
D
F0726No actual harm with potential for more than minimal harm · Isolated
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Deficient, Provider has date of correction · corrected September 13, 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 September 13, 2023
D
F0839No actual harm with potential for more than minimal harm · Isolated
Employ staff that are licensed, certified, or registered in accordance with state laws.
Deficient, Provider has plan of correction · corrected September 13, 2023
D
F0851No actual harm with potential for more than minimal harm · Isolated
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Deficient, Provider has date of correction · corrected September 13, 2023
E
F0730No actual harm with potential for more than minimal harm · Pattern
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected September 13, 2023
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 September 13, 2023
E
F0947No actual harm with potential for more than minimal harm · Pattern
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected September 13, 2023
Inspected July 1, 2021
11 citations · Health
D
F0578No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Deficient, Provider has date of correction · corrected July 31, 2021
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 July 31, 2021
D
F0583No actual harm with potential for more than minimal harm · Isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected July 31, 2021
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 July 31, 2021
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected July 31, 2021
D
F0755No actual harm with potential for more than minimal harm · Isolated
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 July 31, 2021
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected July 31, 2021
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected July 31, 2021
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected July 31, 2021
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected July 31, 2021
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 July 31, 2021
Penalties
Date
Type
Amount
April 8, 2025
Fine
$170,017
December 4, 2024
Fine
$8,357
September 25, 2023
Fine
$4,235
September 18, 2023
Fine
$3,882
September 11, 2023
Fine
$3,529
September 5, 2023
Fine
$3,176
August 28, 2023
Fine
$2,823
August 21, 2023
Fine
$2,470
August 14, 2023
Fine
$2,117
July 24, 2023
Fine
$4,233
Ownership transfers
Effective
Seller
Buyer
12/28/2023
Rural Retreat Care Center LLC
Wythe VA Opco LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.