MOUNTAIN LAUREL REHABILITATION AND NURSING
Open-data reference.
MOUNTAIN LAUREL REHABILITATION AND NURSING is a for profit - limited liability company facility in RURAL RETREAT, VA with 120 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $205K.
514 NORTH MAIN STREET, RURAL RETREAT, VA 24368
Phone: 2766867000
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 495417
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 95
- In Hospital
- No
- County
- Wythe
- Last Inspection
- Apr 8, 2025
- Special Focus
- SFF Candidate
Staffing Data
- RN Hours
- 0.48 (nat'l avg: 0.68)
- LPN Hours
- 1.08
- CNA Hours
- 1.96
- Total Nursing Hours
- 3.51 (nat'l avg: 3.89)
- PT Hours
- 0.10
- Nursing Turnover
- 60.6%
- RN Turnover
- 63.6%
What the CMS Record Reveals About MOUNTAIN LAUREL REHABILITATION AND NURSING
MOUNTAIN LAUREL REHABILITATION AND NURSING operates 120 certified beds in RURAL RETREAT, VA with approximately 95 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 7 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 10 penalties totaling $205K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.51 total nursing hours per resident day (national average 3.89), with RN coverage at 0.48 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, MOUNTAIN LAUREL REHABILITATION AND NURSING falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 60.6%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: May 15, 2025
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.
Category: Administration Deficiencies
Corrected: May 15, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 24, 2025
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.
Category: Administration Deficiencies
Corrected: May 15, 2025
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Category: Administration Deficiencies
Corrected: May 15, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 24, 2025
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Honor each resident's preferences, choices, values and beliefs.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 15, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 24, 2025
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.
Category: Resident Rights Deficiencies
Corrected: May 15, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 15, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: May 15, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: May 15, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 24, 2025
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Category: Nursing and Physician Services Deficiencies
Corrected: May 15, 2025
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: May 15, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 24, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: May 15, 2025
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Category: Administration Deficiencies
Corrected: May 15, 2025
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category: Administration Deficiencies
Corrected: May 15, 2025
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Jun 24, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: May 15, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: May 15, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: May 15, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: May 15, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Jun 24, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: May 15, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 24, 2025
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: May 15, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: May 15, 2025
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Category: Nursing and Physician Services Deficiencies
Corrected: May 15, 2025
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Category: Nursing and Physician Services Deficiencies
Corrected: May 15, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 24, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 15, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 15, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 15, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 15, 2025
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 15, 2025
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.
Category: Resident Rights Deficiencies
Corrected: May 15, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Jun 24, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 15, 2025
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.0% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 16.1% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 39.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 7.4% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.2% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 40.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 94.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 16.5% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.8% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 23.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 12.0% | Yes |
Penalty History 10 penalties totaling $205K
| Date | Type | Amount |
|---|---|---|
| Apr 8, 2025 | Fine | $170K |
| Dec 4, 2024 | Fine | $8K |
| Sep 25, 2023 | Fine | $4K |
| Sep 18, 2023 | Fine | $4K |
| Sep 11, 2023 | Fine | $4K |
| Sep 5, 2023 | Fine | $3K |
| Aug 28, 2023 | Fine | $3K |
| Aug 21, 2023 | Fine | $2K |
| Aug 14, 2023 | Fine | $2K |
| Jul 24, 2023 | Fine | $4K |
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Understanding Nursing Home Data
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County Health Data
Health outcomes, access, and quality metrics for Wythe on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for MOUNTAIN LAUREL REHABILITATION AND NURSING?
What are the staffing levels at MOUNTAIN LAUREL REHABILITATION AND NURSING?
How many beds does MOUNTAIN LAUREL REHABILITATION AND NURSING have?
Does MOUNTAIN LAUREL REHABILITATION AND NURSING have any deficiencies on record?
Has MOUNTAIN LAUREL REHABILITATION AND NURSING received any fines or penalties?
Who owns MOUNTAIN LAUREL REHABILITATION AND NURSING?
When was MOUNTAIN LAUREL REHABILITATION AND NURSING last inspected?
What quality measures are tracked for MOUNTAIN LAUREL REHABILITATION AND NURSING?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.