Mountain View Health & Rehabilitation: Catheter Bag Violation - TX
Federal inspectors flagged the issue during a complaint inspection completed September 5, 2025. The violation was tagged under infection control, rated at minimal harm or potential for actual harm, and affected a small number of residents. The bags, inspectors noted, were not secured to beds or wheelchairs as they should have been.
A catheter drainage bag left on the floor is not a minor housekeeping problem. The bags collect urine directly from a resident's bladder through a catheter. When the bag touches the floor, the risk runs in both directions: contamination from the floor can travel up toward the resident, and pathogens from the bag can spread to the surrounding environment. For elderly residents, many of whom already have compromised immune systems, urinary tract infections can escalate into sepsis.
The assistant director of nursing, identified in the report as ADON F, told inspectors it was the nurse's responsibility to ensure catheter bags were hooked onto the bed. A nurse practitioner identified as NP I said the same thing, in almost the same words, during a separate interview the day before the inspection closed. Catheter bags should not be on the floor, NP I said. It was the nurses' responsibility to ensure they were hooked onto the bed or wheelchair appropriately.
The director of nursing offered a slightly different answer. She agreed the bags were not meant to be on the floor and acknowledged the infection risk. But she said it was everyone's responsibility to make sure the bags were placed correctly.
Everyone's responsibility. The ADON said the nurses. The nurse practitioner said the nurses. The director of nursing said everyone.
None of them described what had actually been done to correct the problem for the residents whose bags had been found on the floor.
The inspection report does not identify how many residents were affected beyond describing it as "few," and it does not detail how long the bags had been positioned incorrectly or whether any resident developed an infection as a result. The report records the deficiency, the staff interviews, and the shared acknowledgment that what was happening was wrong. It does not record a specific corrective action taken on the unit before or during the inspection.
Mountain View Health & Rehabilitation sits on Murchison Road in El Paso and is a Medicare and Medicaid certified facility. This was a complaint inspection, meaning someone, whether a resident, family member, or staff, had contacted regulators before investigators arrived.
The violation itself is not uncommon in nursing homes. Catheter care is one of the more consistently cited infection control failures in long-term care settings, and the positioning of drainage bags is a basic component of that care. Bags hung below bladder level, secured to the bed frame or wheelchair, drain by gravity and reduce the risk of backflow. Bags on the floor do neither.
What the inspection captured here was not a single oversight that staff scrambled to explain. It was a facility where multiple senior clinical staff, when asked about a known infection control problem, each gave a version of the same answer: someone else is in charge of that, or everyone is, which in practice can mean the same thing.
The residents whose catheter bags were on the floor are not named in the report. The inspection does not say whether anyone checked on them between the time the problem was identified and the time the survey closed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Health & Rehabilitation from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
Mountain View Health & Rehabilitation in El Paso, TX was cited for violations during a health inspection on September 5, 2025.
Federal inspectors flagged the issue during a complaint inspection completed September 5, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.