Facility Watch Inspection 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
F0732 No 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
F0557 No 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
F0580 No 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
F0583 No 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
F0622 No 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
F0635 No 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
F0641 No 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
F0645 No 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
F0661 No 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
F0679 No 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
F0686 No 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
F0689 No 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
F0692 No 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
F0695 No 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
F0698 No 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
F0710 No 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
F0711 No 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
F0740 No 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
F0755 No 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
F0756 No 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
F0757 No 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
F0758 No 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
F0759 No 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
F0760 No 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
F0761 No 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
F0773 No 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
F0806 No 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
F0840 No 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
F0841 No 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
F0849 No 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
F0880 No 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
F0883 No 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
F0565 No 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
F0578 No 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
F0584 No 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
F0607 No 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
F0623 No 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
F0625 No 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
F0655 No 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
F0656 No 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
F0658 No 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
F0677 No 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
F0725 No 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
F0770 No 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
F0812 No 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
F0814 No 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
F0842 No 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
F0865 No 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
F0944 No 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
F0675 Actual harm · Isolated

Honor each resident's preferences, choices, values and beliefs.

Deficient, Provider has date of correction · corrected May 15, 2025
G
F0690 Actual 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
F0776 Actual 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
F0777 Actual 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
F0600 Immediate 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
F0684 Immediate 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
F0742 Immediate 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
F0558 No 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
F0584 No 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
F0684 No 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
F0755 No 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
F0760 No 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
F0880 No 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
F0697 Actual 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
F0602 No 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
F0677 No 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
F0684 No 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
F0690 No 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
F0694 No 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
F0710 No 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
F0726 No 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
F0812 No 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
F0839 No 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
F0851 No 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
F0730 No 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
F0842 No 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
F0947 No 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
F0578 No 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
F0580 No 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
F0583 No 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
F0686 No 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
F0692 No 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
F0755 No 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
F0760 No 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
F0883 No 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
F0684 No 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
F0880 No 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
F0812 No 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

DateTypeAmount
April 8, 2025Fine$170,017
December 4, 2024Fine$8,357
September 25, 2023Fine$4,235
September 18, 2023Fine$3,882
September 11, 2023Fine$3,529
September 5, 2023Fine$3,176
August 28, 2023Fine$2,823
August 21, 2023Fine$2,470
August 14, 2023Fine$2,117
July 24, 2023Fine$4,233

Ownership transfers

EffectiveSellerBuyer
12/28/2023Rural Retreat Care Center LLCWythe VA Opco LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.