Mountain Villa Nursing Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 48 beds and averages 38.4 residents a day — about 80% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.15 hrs/resident/day on weekends vs 3.63 on weekdays — 13% thinner on weekends. RN hours go from 0.37 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

• Potential for harm · Ecited before2025-12-04 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two residents (Residents #5, and #8) of seven residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #5 to address residents' blood thinner medication prescription, Eliquis. The facility failed to have a comprehensive person-centered care plan for Resident #8 to address residents' diabetes diagnosis. These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Findings Include:Resident #5 Record review of Resident # 5's admission record dated 12/04/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #5's history and physical dated 09/17/2025 revealed diagnosis of atherosclerotic heart disease of native…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-04 · tag F0940 — failed to train staff — pattern
  Develop, implement, and/or maintain an effective training program for all new and existing staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 1 of 6 facility staff (LVN C) reviewed for trainings consistent with their expected roles, in that; -The facility failed to provide LVN C with training consistent with their expected roles. This failure could place residents at risk of accidents with potential harm due to staff not having up to date training. Findings included: Review of LVN C's personal record revealed annual training by the facility that did not include evidence of training consistent with their expected roles to include Compliance and Ethics, Abuse, Neglect and Exploitation, and Restraint Reduction.In an Interview and Record Review on 12/04/2025 at 2:30 pm with HR personnel revealed that LVN C's last annual trainings for compliance and ethics, restraint reduction, abuse, neglect and exploitation were last completed in September 2018. She stated that LVN C was a nightshift nurse. She stated that even if staff are nightshift, all staff to include nurses and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; and failed to have an established system in place for accurate reconciliation of all controlled drugs for 1 (East wing) of 2 medication carts that had residents with orders for controlled substances.The facility failed to ensure Licensed staff signed the form after counting and verifying that all controlled substances in the East Wing medication cart had been accounted for with the on-coming and off-going nurses on 12/03/25.This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. Record review and interview with LVN D of the facility's Controlled Substance Shift Change Audit Record on the East Wing's Medication Cart, dated 12/03/25, observed at 11:23 AM revealed one signature notated for shift change at 2:00 PM. LVN D…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for one (medication aide's medication cart) of two medications carts reviewed.The Medication Aide B failed to ensure to update label Resident #31's medication Sertraline 100 MG on 12/03/25 with the current dosage instructions to Give 1 tablet by mouth one time a day, to give 25 MG tablet for total dose of 125 MG.This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications.Record review of Resident #31's face sheet dated 12/03/25, revealed a [AGE] year-old male with an admission date 02/18/2022.Record review of Resident #31's history and physical, dated 09/10/25, revealed a medical history of Anxiety (a mental health condition characterized by excessive fear and worry that can interfere with everyday life), and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-20 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans. -The facility failed to ensure Resident #1 's pacemaker was addressed on her care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and could result in injury and a decline in physical well-being. Findings included. Review of Resident #1 face sheet, dated 03/19/2025, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of presence of cardiac pacemaker. Review of Resident #1's Quartely MDS assessment, dated 01/22/2025, reflected Resident #1 had a Brief interview for mental status score of 04 indicating severe cognitive impairment. Presence of pacemaker was listed under her diagnoses. Review of Resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-18 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 3 (CNA A) staff reviewed for EMR. The facility did not have CNA A's EMR on file upon hire. This failure could place residents at risk of abuse, neglect, and misappropriation of property. Findings included: Record review of Abuse and Neglect policy (not dated) read in part All personnel will be screened before hiring criminal history record, background checks, and reference. The licensing board will ne contacted for all licensed personnel to determine if any sanctions have been assessed against the applicant's license. In addition, all nurse aides conduct will be verified through employee misconduct registry. Record review of CNA A's employee files revealed her hire date was 07/19/24. Record review of CNA A's criminal background dated 07/19/24 revealed no findings. Record review of CNA A's employee file revealed no EMR was noted. Interview on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-12 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #3 and Resident #32) reviewed for respect and dignity. The facility failed to ensure staff treated Resident #3 and Resident #32 with respect and dignity, with staff removing residents' trays prior to being completed. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. The findings included: Resident #3 Record review of Resident #3's face sheet dated 09/12/2024 revealed an [AGE] year-old male admitted on [DATE], with the following diagnoses: Vitamin-D deficiency, type 2 diabetes, constipation, mood disturbance, and chronic kidney failure. Record review of Resident #3's Comprehensive MDS dated [DATE] revealed that Section C- Cognitive Patterns had a BIMS score of 06 (severe cognitive…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-12 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, Resident #27, Resident #28, and Resident #36) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed Resident's code status and fall mat. The facility failed to ensure Resident #27's comprehensive care plan addressed Resident #27's code status and PASRR services. The facility failed to ensure Resident #28's comprehensive care plan was resident specific and person centered. The facility failed to ensure Resident #36's comprehensive care plan was resident specific and person centered. These…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-12 · tag F0727 — failed to provide required RN coverage — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 5 (04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; 06/08/2024) of 91 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's Direct Care Staff Daily Report from 04/01/2024 to 06/30/2024 revealed on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024 there was no evidence of RN coverage. During an interview on 9/12/2024 at 3:15 PM, the DON stated her expectation was to have RN coverage daily. The DON stated she was on call on weekends and can be contacted when there was not a RN…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-12 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 of 6 residents (Resident #28 & Resident #198) reviewed for medication errors. 1. The facility failed to ensure MA administered the correct dose of calcium and vitamin D to Resident #28 according to the physician orders. 2. The facility failed to ensure MA administered olmesartan medoxomil (for blood pressure) and amlodipine besylate (for blood pressure) to Resident #198 according to physician orders. These failures could place residents at risk of inadequate therapeutic outcomes. Findings included: Resident #28 Record review of Resident #28's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: osteoarthritis (when the cartilage that cushions and protects the ends of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX