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Mountain Villa Nursing Home
2729 Porter Ave, El Paso, TX 79930 · CMS Certification Number (CCN) 675768
At a glance
- CMS overall rating
- ★★★★☆ 4 of 5
- Health inspection citations
- 23 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 2 from complaints)
- Fire safety citations
- 29
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- December 4, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★★☆ 4 of 5 | 2.7 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.8 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 1.9 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
| Short-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | December 4, 2025 | 4 | 4 | 0 |
| Cycle 2 | September 12, 2024 | 11 | 9 | 2 |
CMS weighted health inspection score: 36 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
23 health citations across 5 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
December 4, 2025: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/30/2025 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/30/2025 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/30/2025 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/30/2025 |
March 20, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/07/2025 |
November 18, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/30/2024 |
September 12, 2024: 9 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| E | F-0803 | 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. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| E | F-0727 | 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. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| D | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/15/2024 |
August 9, 2023: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
| C | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
| D | F-0693 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
| E | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/30/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
29 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 12/04/2025 | E | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0364 | Install properly constructed windows in hallway walls or doors. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/04/2026 |
| 12/04/2025 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | K-0300 | Meet other general requirements that are deficient. Egress Deficiencies | Deficient, Provider has date of correction Corrected 06/04/2026 |
| 12/04/2025 | F | 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. Egress Deficiencies | Deficient, Provider has date of correction Corrected 06/04/2026 |
| 12/04/2025 | F | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | E-0029 | Develop a communication plan. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 12/04/2025 | F | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/10/2026 |
| 09/12/2024 | F | K-0751 | Have restrictions on the use of flammable curtains. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 10/11/2024 |
| 09/12/2024 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 10/11/2024 |
| 09/12/2024 | D | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/11/2024 |
| 09/12/2024 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/11/2024 |
| 08/09/2023 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 09/30/2023 |
| 08/09/2023 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/30/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.49 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.35 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.65 | Not published | Not published |
| Nurse aide hours per resident per day | 2.5 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.15 | Not published | Not published |
| RN hours per resident per day, weekends | 0.3 | Not published | Not published |
| Total nursing staff turnover (%) | 43.9 | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- J Squared, INC.
- Ownership type
- For profit - Corporation
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 48
- Average residents per day
- 38.4
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- September 1, 1998
- County/parish
- El Paso
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
4 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| MAHARLIKA RESOURCES, INC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| RIVERA, DONOVAN | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| RIVERA, DONOVAN | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MAHARLIKA RESOURCES, INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Mountain Villa Nursing Home. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.