Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MOUNTAIN VILLA NURSING HOME
EL PASO, TX · 48 certified beds · Last Life Safety survey December 4, 2025
CMS Certification Number 675768 · first certified September 1998
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
29 citations — more than 99% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 23 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 3 months from now. This facility’s last Life Safety survey was December 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 29 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 9, 2023 | 2 |
| September 12, 2024 | 4 |
| December 4, 2025 | 23 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2025-12-04 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-12-04 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-12-04 |
| K-0364 | Install properly constructed windows in hallway walls or doors. | 1 | 2025-12-04 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-12-04 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2025-12-04 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-12-04 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-12-04 |
What the citations cover
- Smoke Deficiencies 14
- Emergency Preparedness Deficiencies 6
- Egress Deficiencies 3
- Services Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 14 |
| Emergency Preparedness Deficiencies | 6 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 4, 2025 — 23 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 10, 2026) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (May 10, 2026) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (May 10, 2026) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (May 10, 2026) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (May 10, 2026) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (June 4, 2026) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (June 4, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 4, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0364 | Install properly constructed windows in hallway walls or doors. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 10, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 10, 2026) |
September 12, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0751 | Have restrictions on the use of flammable curtains. | Deficient, Provider has date of correction (October 11, 2024) |
August 9, 2023 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 30, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (September 30, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.