Casa Maria Healthcare: Bathing Neglect Violations - NM
The resident, identified in inspection records as Resident 3, carried a cognitive score of zero on a standardized assessment scale, meaning total impairment. She could not walk independently, could not coordinate her own movements, and required one staff member to assist her completely through every shower. She could not ask for help. She could not complain. She could not tell anyone she hadn't been bathed in nearly three weeks.
The facility's own shower schedule called for her to be washed on Mondays, Wednesdays, and Fridays.
Inspectors reviewed her August 2025 documentation and found two showers recorded for the entire month: August 6 and August 25. Between those two dates, eighteen days passed with no record of a bath, a shower, or even an offer of either. Before the first shower, five days elapsed after her admission with nothing documented. After the second shower, the month ended with six more days unaccounted for, except for a single refusal noted on August 26.
One refusal in thirty-one days. Two showers. A woman who couldn't speak for herself.
The facility's regional nurse consultant, interviewed by inspectors on September 2, confirmed that her expectation was for the shower schedule to be followed. She confirmed it wasn't, and not just for Resident 3. The same failure applied to Resident 1 and Resident 2 as well.
She didn't say how long those residents had gone without bathing. The inspection report doesn't say either. What it says is that the person whose job it was to set expectations acknowledged, plainly, that those expectations had not been met for at least three people in her care.
Dementia patients who cannot bathe themselves are among the most dependent people in any nursing facility. They rely entirely on staff to notice, to show up, and to follow through. When staff don't, the resident has no recourse. There is no call to make, no complaint to file, no way to signal distress to someone outside the building. The only record of what happened, or didn't happen, is whatever staff chose to document, and here the documentation showed almost nothing because almost nothing was done.
The inspection was conducted as a complaint survey, meaning someone from outside the facility, or possibly inside it, raised a concern serious enough to trigger a federal review. The inspectors who arrived found what the records confirmed: a scheduled hygiene routine that existed on paper and almost nowhere else.
Casa Maria Healthcare is a long-term care facility in Roswell, serving residents whose diagnoses, in Resident 3's case, included unspecified dementia, muscle weakness, lack of coordination, and difficulty walking. Those aren't incidental details. They are the clinical portrait of someone who cannot do for herself what the facility agreed to do when she was admitted.
The violation was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. Whether eighteen days without bathing causes measurable physical injury is a clinical question. What it causes in terms of dignity is not.
The regional nurse consultant's confirmation that the shower schedule wasn't followed for three residents suggests this wasn't a single aide forgetting a single shift. It was a pattern, across multiple residents, that persisted through an entire month before anyone from outside the facility looked at the records.
Resident 3 had a score of zero. She needed maximum assistance for everything. She was scheduled for a shower three times a week. She got two in August.
Nobody documented why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa Maria Healthcare from 2025-09-11 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 21, 2026 · Our methodology
Casa Maria Healthcare in Roswell, NM was cited for neglect violations during a health inspection on September 11, 2025.
The resident, identified in inspection records as Resident 3, carried a cognitive score of zero on a standardized assessment scale, meaning total impairment.
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.