Federal inspection record · CMS data as of October 1, 2026
Mountain Laurel Rehabilitation And Nursing
514 North Main Street, Rural Retreat, VA · (276) 686-7000
- Cited for abuse (CMS abuse icon)
- Special Focus Facility
- Certified beds
- 120
- Residents per day
- 94
- Ownership
- For-Profit
- Chain
- Eastern Healthcare Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- January 29, 2015
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Virginia.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Virginia homes
Mountain Laurel Rehabilitation And Nursing carries 663 inspection points. That is fewer than 1% of Virginia's 287 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Virginia: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–16 pts
- 4★ 16–45 pts
- 3★ 45–76.5 pts
- 2★ 76.5–168.75 pts
- 1★ over 168.75 pts
Bars show every rated home in Virginia by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
87 health citations on record since 2021. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (8)
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
J
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.
-
G
Honor each resident's preferences, choices, values and beliefs.
-
G
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
-
G
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
-
G
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
-
G
Provide safe, appropriate pain management for a resident who requires such services.
Everything else, by area of care
Quality of Life and Care16E
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide activities to meet all resident's needs.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide enough food/fluids to maintain a resident's health.
Resident Rights14E
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- E
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.
- E
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.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- E
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.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Keep residents' personal and medical records private and confidential.
- D
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.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
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.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Keep residents' personal and medical records private and confidential.
Pharmacy Service11D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure that residents are free from significant medication errors.
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure that residents are free from significant medication errors.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure that residents are free from significant medication errors.
Resident Assessment and Care Planning9E
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
- D
Ensure each resident receives an accurate assessment.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Nursing and Physician Services9E
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
- D
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
- C
Post nurse staffing information every day.
- E
Observe each nurse aide's job performance and give regular training.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
- D
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.
Administration8E
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
- E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
- D
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.
- D
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.
- D
Employ staff that are licensed, certified, or registered in accordance with state laws.
- D
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Nutrition and Dietary5F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Dispose of garbage and refuse properly.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control5E
- D
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Freedom from Abuse, Neglect, and Exploitation2E
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspection history
2025-04-08
56 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
2023-08-14
20 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2021-07-01
11 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 24 min of nursing staff time a day, 22 min of it from a registered nurse.
This home
3 h 24 min
Virginia average
3 h 53 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 55% of nursing staff and 20% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$143,729 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-04-08 | Fine | $135,372 |
| 2024-12-04 | Fine | $8,357 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.2 pts better | 1.2 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1 pts worse | 2.4 | 1.4 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine49.4 pts worse | 41.8% | 91.2% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine25.6 pts worse | 67.7% | 93.3% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.2 pts worse | 5.7% | 3.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms6.7 pts better | 13.8% | 20.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.1 pts worse | 6.4% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication12.6 pts worse | 33.3% | 20.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.7 pts better | 11.5% | 14.2% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened9.5 pts better | 4.7% | 14.2% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased6.9 pts better | 7.6% | 14.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.4 pts better | 0.0% | 0.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.6 pts worse | 3.2% | 1.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.2 pts better | 16.1% | 21.3% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.7 pts better | 2.7% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine63.5 pts worse | 10.7% | 74.2% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit19.1 pts worse | 30.6% | 11.5% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication2.6 pts worse | 3.9% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine53.6 pts worse | 19.7% | 73.3% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.5 pts worse | 26.5% | 22.0% | 23.4% |
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Who owns and runs it
19 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Va SNF Operations Holdings LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 11 facilities |
| Lyam Family Trust | 5% Or Greater Indirect Ownership Interest · Organization | 50% | 3 facilities |
| Apex Global Solutions LLC | Indirect Ownership Interest · Organization | 0% | 8 facilities |
| Capital Funding Group | 5% Or Greater Mortgage Interest · Organization | 0% | 1 facilities |
| Capital Funding Group | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Gittleson, Layla | Indirect Ownership Interest · Individual | 0% | 4 facilities |
| Gittleson, Yehuda | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Gittleson, Yehuda | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Gittleson, Yehuda | Trustee Of The SNF · Individual | 0% | 4 facilities |
| Hajimomenian, Amir | Operational/Managerial Control · Individual | 0% | 13 facilities |
| Hartman, Aaron | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Shapiro, Akiva | Corporate Officer · Individual | 0% | 18 facilities |
| Shapiro, Akiva | Operational/Managerial Control · Individual | 0% | 18 facilities |
| Sommer, Nechama | Operational/Managerial Control · Individual | 0% | 7 facilities |
| Va SNF Master Consulting LLC | Operational/Managerial Control · Organization | 0% | 4 facilities |
| Va SNF Operations Holdings 3 LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Ydi Eastern Holdco LLC | Indirect Ownership Interest · Organization | 0% | 3 facilities |
| Ydi Eastern Holdco LLC | Operational/Managerial Control · Organization | 0% | 3 facilities |
| Ydi Irrevocable Trust | Indirect Ownership Interest · Organization | 0% | 3 facilities |
·
Fire safety
15 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke6E
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Meet other general requirements.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Install corridor and hallway doors that block smoke.
- D
Have approved installation, maintenance and testing program for fire alarm systems.
Emergency Preparedness2D
- D
Establish staff and initial training requirements.
- D
Establish staff and initial training requirements.
Egress2E
- D
Install emergency lighting that can last at least 1 1/2 hours.
- E
Have properly located and lighted "Exit" signs.
Services2F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Have properly installed electrical wiring and gas equipment.
Gas, Vacuum, and Electrical Systems2F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D
Ensure proper usage of power strips and extension cords.
Miscellaneous1E
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
·
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-
Francis Marion Manor Health & Rehabilitation
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