MOUNTAIN LAUREL REHABILITATION AND NURSING
514 NORTH MAIN STREET, RURAL RETREAT, VA, 24368 · 2766867000
Legal business name: WYTHE VA OPCO LLC
What CMS has flagged
- CMS has flagged this facility for abuse citations.
On the CMS record
- Overall rating (CMS)
- 1 / 5
- Health inspection rating
- 1 / 5
- Staffing rating
- 2 / 5
- Certified beds
- 120
- Ownership type
- For profit - Limited Liability company
- Chain
- EASTERN HEALTHCARE GROUP
Inspection findings on record (87)
Quoted exactly as CMS published them. We do not rewrite findings.
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Honor each resident's preferences, choices, values and beliefs.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Recorded as corrected on .
— Administration Deficiencies
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Recorded as corrected on .
— Administration Deficiencies
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Recorded as corrected on .
— Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Recorded as corrected on .
— Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Recorded as corrected on .
— Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Recorded as corrected on .
— Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Recorded as corrected on .
— Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Recorded as corrected on .
— Administration Deficiencies
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.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Recorded as corrected on .
— Administration Deficiencies
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.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Recorded as corrected on .
— Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
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.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Recorded as corrected on .
— Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Recorded as corrected on .
— Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Recorded as corrected on .
— Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 495417