Inspection visit
Fire Safety inspection
Citations
23 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0300GeneralS&S Fpotential for harm
Meet other general requirements that are deficient.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0341GeneralS&S Epotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0343GeneralS&S Epotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0222GeneralS&S Fpotential for harm
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.
- 0361GeneralS&S Epotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0364GeneralS&S Epotential for harm
Install properly constructed windows in hallway walls or doors.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the December 4, 2025 survey of MOUNTAIN VILLA NURSING CENTER?
This was a inspection survey of MOUNTAIN VILLA NURSING CENTER on December 4, 2025. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MOUNTAIN VILLA NURSING CENTER on December 4, 2025?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.