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Complaint Investigation

Casa Maria Healthcare

Inspection Date: September 11, 2025
Total Violations 2
Facility ID 325086
Location Roswell, NM
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Inspection Findings

F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review and interview, the facility failed to report a suicide attempt where a potential for serious bodily injury can occur within 24 hours to the State Agency (SA) for 1 (R #2) of 1 (R #2) resident reviewed for abuse. If the facility fails to report these incidents to the State Agency, then the State Agency cannot ensure the residents' safety is protected. The findings are: 1. Record review of the facility's Initial Incident Report for R #1's suicide attempt on 09/01/25 revealed the initial report was submitted to the SA

on 09/10/25. 2. On 09/11/25 at 2:15 pm during an interview with the Regional Nurse Consultant, she confirmed that the report was not submitted timely within 24 hours.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casa Maria Healthcare

1601 South Main Street Roswell, NM 88203

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0677

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the following diagnoses:1. Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Muscle weakness,3. Lack of coordination,4. Difficulty in walking.M. Record review of R #3's quarterly Minimum Data Set, dated [DATE REDACTED] revealed the following:1. BIM score of 00, severe impairment.2. R #3 is totally dependent with maximum assistance to shower or bathe.N. Record review of the facility's shower schedule, no date, revealed R #3 is scheduled for a shower on Mondays, Wednesdays, and Fridays.O. Record review of R #3's survey documentation report for the month of August 2025 revealed the following:1. R #3 was showered on 08/06/25, and 08/25/25 with total dependence and one-person assist.2. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for five days from admission, days from 08/01/25 to 08/06/25.3. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for eighteen days, from 08/07/25 to 08/25/25.4. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for six days from 08/26/25 to 08/31/25.5. The survey documentation report revealed R #3 refused a bath or shower on 08/26/25.P. On 09/02/25 at 11:02 am

during an interview with the Regional Nurse Consultant (RNC #1), she stated her expectation is for the shower schedule to be followed and confirmed it was not for R #1, R #2, and R #3.

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

Casa Maria Healthcare in Roswell, NM inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Roswell, NM, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Casa Maria Healthcare or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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