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Complaint Investigation

Sunset Villa Healthcare

September 2, 2025 · Roswell, NM · 1515 South Sunset Avenue
Citations 1
CMS Rating 3/5
Beds 52
Provider ID 325117
Healthcare Facility
Sunset Villa Healthcare
Roswell, NM  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Sunset Villa Healthcare in Roswell, NM — inspection on September 2, 2025.

Found 1 citation. Severity: Standard violations.

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

Inspection Findings

FF0677
Quality of Life and Care Deficiencies

The survey documentation report did not contain any documentation to show R #2 was assisted with a bath or shower for seven days from 08/05/25 to 08/12/25. 4.

The survey documentation report did not contain any documentation to show R #2 was assisted with a bath or shower for seven days from 08/21/25 to 08/28/25. R #3N.

Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses: 1.

Unspecified dementia2.

Adult failure to thrive3.

Need for assistance with personal careO.

Record review of R #3's quarterly Minimum Data Set, dated [DATE], revealed the following: 1. BIM score of 07, severe impairment.2. R #3 requires partial to moderate assistance to shower or bathe. P.

Record review of the facility's shower schedule, no date, revealed R #3 is scheduled for a shower on Mondays, Wednesdays, and Fridays.Q.

Record review of R #3's survey documentation report for the month of August 2025 revealed the following: 1. R #3 was showered on 08/04/25, 08/11/25, and 08/21/25. 2. R #3 refused to be showered on 08/09/25, 08/18/25, 08/21/25, 08/28/25, 08/30/25, and 08/31/25. 3.The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for five days from 08/04/25 to 08/29/25. 4.

The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for seven days from 08/11/25 to 08/18/25.

R. On 09/02/25 at 11:02 am during an interview with the Administrator (ADM), she stated her expectation is for the shower schedule to be followed and confirmed it was not.

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 Sunset Villa Healthcare or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.