Mountain Villa Nursing Home

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.5 to 3.1 hours per resident per day.

• Name

  CMS lists a new name for this home. It was MOUNTAIN VILLA NURSING CENTER.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on December 30, 2025.

  CMS has cited this home for F0656 4 times since 2023.

• Citation F0940. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop, implement, and/or maintain an effective training program for all new and existing staff members.

  CMS lists it as corrected on December 30, 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on December 30, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 30, 2025.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on May 10, 2026.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on May 10, 2026.

• Citation E0018. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish procedures for tracking staff and patients during an emergency.

  CMS lists it as corrected on May 10, 2026.

• Citation E0026. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish roles under a Waiver declared by secretary.

  CMS lists it as corrected on May 10, 2026.

• Citation E0029. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on May 10, 2026.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on May 10, 2026.

• Citation K0211. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on May 10, 2026.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on June 4, 2026.

• Citation K0300. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet other general requirements that are deficient.

  CMS lists it as corrected on June 4, 2026.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on May 10, 2026.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on May 10, 2026.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on May 10, 2026.

  CMS has cited this home for K0353 3 times since 2023.

• Citation K0372. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on May 10, 2026.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on May 10, 2026.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on May 10, 2026.

• Citation K0341. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on May 10, 2026.

• Citation K0343. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

  CMS lists it as corrected on May 10, 2026.

• Citation K0351. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on June 4, 2026.

• Citation K0361. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

  CMS lists it as corrected on May 10, 2026.

• Citation K0364. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install properly constructed windows in hallway walls or doors.

  CMS lists it as corrected on May 10, 2026.

• Citation K0374. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on May 10, 2026.

• Citation K0521. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on May 10, 2026.

  CMS has cited this home for K0521 3 times since 2023.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on May 10, 2026.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on April 7, 2025.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0607. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on November 30, 2024.

  CMS has cited this home for F0607 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on October 15, 2024.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on October 15, 2024.

• Citation F0727. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on October 15, 2024.

• Citation F0759. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on October 15, 2024.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on October 15, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on October 15, 2024.

  CMS has cited this home for F0812 2 times since 2023.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 15, 2024.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on October 15, 2024.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on October 15, 2024.

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CMS lists this as a standard inspection.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on October 11, 2024.

• Citation K0751. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have restrictions on the use of flammable curtains.

  CMS lists it as corrected on October 11, 2024.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on October 11, 2024.

• Citation K0521. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on October 11, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0607. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on September 30, 2023.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 30, 2023.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on September 30, 2023.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on September 30, 2023.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 30, 2023.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on September 30, 2023.

• Citation F0814. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on September 30, 2023.

• Citation F0732. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on September 30, 2023.

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CMS lists this as a standard inspection.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on September 30, 2023.

• Citation K0521. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on September 30, 2023.

See this home on CMS Care Compare