Cycle 1
Health 2025-12-04 · Fire 2024-09-12
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
El Paso, TX
Mountain Villa Nursing Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2729 Porter Ave, El Paso, TX
(915) 566-2111
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.95
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,569
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9893
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.41
Baseline 25.00% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 0
Adjusted total nurse staffing
0.74
Baseline 3.63 hours · Performance 3.29 hours · Measure score 0.74 · Achievement 0.74 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 88.46% |
95.27%
6.8 pts worse
|
Numerator 23 · Denominator 26 |
| Falls with major injury | 3.85% |
0.77%
3.1 pts worse
|
Numerator 1 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 60 |
| Staff flu vaccination coverage | 36.67% |
42%
5.3 pts worse
|
Numerator 22 · Denominator 60 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
97.1%
1.2 pts worse
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 100.0% · Q3 95.1% · Q4 92.3% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.3% |
97.9%
6.6 pts worse
|
95.5%
4.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.3%
0.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.5% · Q3 2.4% · Q4 5.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
2.7%
4 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.0% · Q3 5.0% · Q4 7.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
3.3%
4.2 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 13.9% · Q3 10.8% · Q4 2.9% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
18.9%
12 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 40.0% · Q3 23.7% · Q4 20.0% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
10.8%
9 pts worse
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 12.9% · Q3 18.5% · Q4 29.2% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.3% |
15.4%
12.9 pts worse
|
16.3%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.9% |
16.1%
17.8 pts worse
|
14.9%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 46.9% · Q3 33.3% · Q4 36.7% · 4Q avg 33.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
0.5%
1.8 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.8% · Q3 1.7% · Q4 1.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
0.8%
2.3 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.5% · Q3 2.5% · Q4 2.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.5% |
15.0%
3.5 pts better
|
19.8%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 8.0% · Q3 14.3% · Q4 2.6% · 4Q avg 11.5% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.2%
0.4 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 3.4% · Q3 1.6% · Q4 5.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
89.7%
1.7 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 91.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2023-08-09
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-08-09 · Fire 2022-06-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-12
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-11
C · Minimal harm
2024-09-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-11
E · Potential for more than minimal harm
2023-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-30
C · Minimal harm
2023-08-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-30
C · Minimal harm
2022-06-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-12-04
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-03-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-07
D · Potential for more than minimal harm
2024-11-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-09-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-12
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-12
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-09-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-09-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-15
E · Potential for more than minimal harm
2023-08-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-09
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-09-30
C · Minimal harm
2023-08-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-30
Penalties and ownership
What sits behind the stars
Ownership
Maharlika Resources, Inc
5% Or Greater Direct Ownership Interest · Organization
Maharlika Resources, Inc
Operational/Managerial Control · Organization
Rivera, Donovan
5% Or Greater Direct Ownership Interest · Individual
Rivera, Donovan
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Nazareth Living Care Center
El Paso, TX
3-star overall rating with 2-star inspections with 24 recent health deficiencies with 26 fire-safety deficiencies in the latest cycle
#2
Mountain View Health & Rehabilitation
El Paso, TX
1-star overall rating with 1-star inspections with abuse icon flag with $127,645 in total fines with 27 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Grace Pointe Wellness Center
El Paso, TX
2-star overall rating with 1-star inspections with abuse icon flag with $76,402 in total fines with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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