Your report for Mountain Laurel Rehabilitation and Nursing
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- VirginiaLowest tier among peers285 rated homes · average 3.0★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs VA avg
- StaffingCan add or remove a star2★−0.5 vs VA avg
- Quality measuresCan add or remove a star3★−0.9 vs VA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersVA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 30% of peersVA avg2.5★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 12% of peersVA avg3.9★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.51hrsAbove 51% of peersVA avg3.82Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.48hrsAbove only 42% of peersVA avg0.69Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better61%Above only 18% of peersVA avg48%RN turnover64%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$204,839Above only 1% of peersVA avg$16,279Fines · denials10 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthJul 2021 – Apr 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Apr 8, 2025Cycle 1worst J · immediate jeopardy$170,017
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected May 15, 2025
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jun 24, 2025
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationE · patternCorrected May 15, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Jun 24, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected May 15, 2025
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected May 15, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jun 24, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected May 15, 2025
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 15, 2025
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected May 15, 2025
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected May 15, 2025
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 15, 2025
- F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationE · patternCorrected Jun 24, 2025
- F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected May 15, 2025
- F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.AdministrationG · isolatedCorrected May 15, 2025
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected May 15, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jun 24, 2025
- F814Dispose of garbage and refuse properly.Nutrition and DietaryE · patternCorrected May 15, 2025
- F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Nursing and Physician ServicesD · isolatedCorrected May 15, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 24, 2025
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected May 15, 2025
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected May 15, 2025
- F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected May 15, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Jun 24, 2025
- F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care PlanningD · isolatedCorrected May 15, 2025
- F675Honor each resident's preferences, choices, values and beliefs.Quality of Life and CareG · isolatedCorrected May 15, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected May 15, 2025
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected May 15, 2025
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected May 15, 2025
- F742Provide 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.Quality of Life and CareJ · isolatedCorrected May 15, 2025
- F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.AdministrationG · isolatedCorrected May 15, 2025
- F840Employ 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.AdministrationD · isolatedCorrected May 15, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Jun 24, 2025
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected May 15, 2025
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationE · patternCorrected May 15, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 15, 2025
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected May 15, 2025
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected May 15, 2025
- F578Honor 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.Resident RightsE · patternCorrected May 15, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jun 24, 2025
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected May 15, 2025
- F584Honor 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.Resident RightsE · patternCorrected May 15, 2025
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected May 15, 2025
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Jun 24, 2025
- F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Resident Assessment and Care PlanningD · isolatedCorrected May 15, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 15, 2025
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected May 15, 2025
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected May 15, 2025
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected May 15, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 15, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareG · isolatedCorrected May 15, 2025
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected May 15, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 24, 2025
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 15, 2025
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesD · isolatedCorrected May 15, 2025
- F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Nursing and Physician ServicesD · isolatedCorrected May 15, 2025
Dec 4, 2024Cycle 2worst G · actual harm$8,357
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jan 31, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 31, 2025
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jan 23, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jan 31, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jan 31, 2025
- F584Honor 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.Resident RightsD · isolatedCorrected Jan 31, 2025
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareG · isolatedCorrected Jan 23, 2025
Aug 14, 2023Cycle 2worst E · no actual harm$2,823, $2,470, $2,117
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Sep 13, 2023
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 13, 2023
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesD · isolatedCorrected Sep 13, 2023
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Sep 13, 2023
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Sep 13, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Sep 13, 2023
- F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationD · isolatedCorrected Sep 13, 2023
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Sep 13, 2023
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationD · isolatedCorrected Sep 13, 2023
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Sep 13, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Sep 13, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 13, 2023
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 13, 2023
Jul 1, 2021Cycle 3worst F · no actual harm
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Jul 31, 2021
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Jul 31, 2021
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 31, 2021
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jul 31, 2021
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 31, 2021
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 31, 2021
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Jul 31, 2021
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jul 31, 2021
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jul 31, 2021
- F578Honor 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.Resident RightsD · isolatedCorrected Jul 31, 2021
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jul 31, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.51hrs
- Registered nursesRN hours only0.48hrs
- Licensed practical nursesLPN hours1.08hrs
- Nurse aidesCNA hours1.96hrs
- Weekend nursingAll staff on Saturdays and Sundays2.90hrs
- Virginia average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better61%Above only 18% of peersVA avg 48%
- RN turnoverRegistered nurses only64%Not ranked by CMS
- Administrators who leftIn the past year2Leadership changed
- Occupancy120 certified beds · ~95 residents a day79%Above only 15% of peersVA avg 87%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $204,839In fines
- 10Fines
- 0Payment denials
- $16,279VA avg in fines
Actions on record
- Apr 8, 2025Civil money penalty$170,017
- Dec 4, 2024Civil money penalty$8,357
- Sep 25, 2023Civil money penalty$4,235
- Sep 18, 2023Civil money penalty$3,882
- Sep 11, 2023Civil money penalty$3,529
- Sep 5, 2023Civil money penalty$3,176
- Aug 28, 2023Civil money penalty$2,823
- Aug 21, 2023Civil money penalty$2,470
- Aug 14, 2023Civil money penalty$2,117
- Jul 24, 2023Civil money penalty$4,233
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Eastern Healthcare Group17 facilities in the chain1.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- VA SNF Operations Holdings LLC
- Lyam Family Trust
- Ydi Irrevocable Trust
- Capital Funding Group
- VA SNF Master Consulting LLC
- VA SNF Operations Holdings 3 LLC
- Ydi Eastern Holdco LLC
- Yehuda Gittleson
- Amir Hajimomenian
- Aaron Hartman
- Akiva Shapiro
- +1 more
- Akiva Shapiro
- Capital Funding Group
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 495417 · 514 NORTH MAIN STREET, RURAL RETREAT, VA, 24368.
- Percentiles compare this facility with every rated nursing home in Virginia and Wythe County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









