MOUNTAIN LAUREL REHABILITATION AND NURSING — Nursing Home in RURAL RETREAT, VA

CMS Five-Star Rating

Based on health inspections, staffing, and quality measures

Health Inspection Findings & Deficiencies

MOUNTAIN LAUREL REHABILITATION AND NURSING had 56 health inspection deficiencies on its most recent inspection (April 8, 2025), including 7 classified as severe.

Inspection Findings — April 8, 2025

• Provide enough food/fluids to maintain a resident's health. (Level D)
  Corrected — May 15, 2025
• Post nurse staffing information every day. (Level C)
  Corrected — May 15, 2025
• Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (Level D)
  Corrected — May 15, 2025
• Honor the resident's right to organize and participate in resident/family groups in the facility. (Level E)
  Corrected — May 15, 2025
• 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. (Level E)
  Corrected — May 15, 2025
• Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Level D)
  Corrected — June 24, 2025
• 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. (Level E)
  Corrected — May 15, 2025
• Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Level E)
  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. (Level E)
  Corrected — June 24, 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. (Level E)
  Corrected — May 15, 2025
• Provide doctor's orders for the resident's immediate care at the time the resident was admitted. (Level D)
  Corrected — May 15, 2025
• Ensure each resident receives an accurate assessment. (Level D)
  Corrected — May 15, 2025
• PASARR screening for Mental disorders or Intellectual Disabilities (Level D)
  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 (Level E)
  Corrected — May 15, 2025
• Ensure services provided by the nursing facility meet professional standards of quality. (Level E)
  Corrected — May 15, 2025
• Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Level D)
  Corrected — May 15, 2025
• Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Level D)
  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. (Level G)
  Corrected — May 15, 2025
• Provide safe and appropriate respiratory care for a resident when needed. (Level D)
  Corrected — June 24, 2025
• Provide safe, appropriate dialysis care/services for a resident who requires such services. (Level D)
  Corrected — May 15, 2025
• Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. (Level D)
  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. (Level D)
  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. (Level E)
  Corrected — May 15, 2025
• Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Level D)
  Corrected — June 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. (Level D)
  Corrected — May 15, 2025
• Ensure each resident’s drug regimen must be free from unnecessary drugs. (Level D)
  Corrected — June 24, 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. (Level D)
  Corrected — May 15, 2025
• Ensure medication error rates are not 5 percent or greater. (Level D)
  Corrected — May 15, 2025
• Ensure that residents are free from significant medication errors. (Level D)
  Corrected — May 15, 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. (Level D)
  Corrected — May 15, 2025
• Provide timely, quality laboratory services/tests to meet the needs of residents. (Level E)
  Corrected — June 24, 2025
• Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. (Level D)
  Corrected — May 15, 2025
• Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. (Level G)
  Corrected — May 15, 2025
• Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (Level D)
  Corrected — May 15, 2025
• Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Level E)
  Corrected — June 24, 2025
• Dispose of garbage and refuse properly. (Level E)
  Corrected — May 15, 2025
• Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. (Level D)
  Corrected — May 15, 2025
• Provide and implement an infection prevention and control program. (Level D)
  Corrected — June 24, 2025
• Develop and implement policies and procedures for flu and pneumonia vaccinations. (Level D)
  Corrected — May 15, 2025
• Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. (Level E)
  Corrected — May 15, 2025
• Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Level J)
  Corrected — May 15, 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. (Level D)
  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. (Level E)
  Corrected — June 24, 2025
• Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Level D)
  Corrected — May 15, 2025
• Honor each resident's preferences, choices, values and beliefs. (Level G)
  Corrected — May 15, 2025
• Provide care and assistance to perform activities of daily living for any resident who is unable. (Level E)
  Corrected — May 15, 2025
• Provide activities to meet all resident's needs. (Level D)
  Corrected — May 15, 2025
• Provide appropriate treatment and care according to orders, resident’s preferences and goals. (Level J)
  Corrected — June 24, 2025
• Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Level D)
  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. (Level J)
  Corrected — May 15, 2025
• Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. (Level G)
  Corrected — May 15, 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. (Level D)
  Corrected — May 15, 2025
• Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Level E)
  Corrected — June 24, 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. (Level D)
  Corrected — May 15, 2025
• Have a plan that describes the process for conducting QAPI and QAA activities. (Level E)
  Corrected — May 15, 2025
• Keep residents' personal and medical records private and confidential. (Level D)
  Corrected — May 15, 2025

Frequently Asked Questions

Data Source

This information is sourced from official CMS (Centers for Medicare & Medicaid Services) public datasets.

CMS Provider Information updated May 1, 2026.

CMS Survey Summary updated May 1, 2026.

CMS Health Deficiencies updated May 1, 2026.

CareQED last updated June 22, 2026.

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