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Complaint Investigation

Sunset Villa Healthcare

Inspection Date: November 21, 2025
Total Violations 3
Facility ID 325117
Location Roswell, NM
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Inspection Findings

F-Tag F0600

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

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on record review and interview, the facility failed to keep residents free from abuse for 1 (R #1) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed for abuse when Certified Nurse Aide (CNA) #1 was verbally abusive to R #1. This deficient practice led to R #1 feeling embarrassed. The findings are: A.

Record review of the facility's Initial Incident Report dated 10/06/25 revealed that on 10/03/25 CNA #1 yanked (pulled) R #1 by her left arm while assisting her into a sitting position and made fun of her financial situation by telling her the driver was going to take her to another facility because she couldn't afford her bills.B. On 11/20/25 at 1:15 pm, during an interview with R #, she stated she does not feel like CNA #1 meant to hurt her, but she does not like to be rushed, and he was rushing her. R #1 stated he made her feel embarrassed because he was laughing at her financial situation by telling her the driver was going to take her to another facility since she couldn't pay her bills.C. Record review of CNA #1's training file revealed CNA #1 received training on abuse, neglect, and exploitation and training on resident rights on 07/04/25.D.

Record review of CNA #1's termination form dated 10/06/25 revealed that CNA #1's employment at the facility was terminated due to abuse.E. On 11/21/25 at 9:20 am during an interview with the Administrator (ADM), she confirmed CNA #1's employment with the facility was terminated on 10/06/25 due to abuse.

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

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Villa Healthcare

1515 South Sunset Avenue 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 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 - Some

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

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 allegations of abuse and neglect to the State Agency within twenty-four hours for 3 (R #1, R #2, and R #3) of 5 (R #1, R #2, R #3, R #4, and R #6) residents reviewed for abuse and neglect. If the facility fails to report allegations of abuse and neglect to the State Agency, then the State Agency is unable to ensure residents are free from abuse and neglect. The findings are: A. Record review of the facility's Initial Incident Report dated 10/06/25 revealed that on 10/03/25 CNA #1 yanked (pulled) R #1 by her left arm while assisting her into a sitting position and made fun of her financial situation by telling her the driver was going to take her to another facility because she couldn't afford her bills. B. Record review of the facility's Initial Incident Report dated 09/30/25, received by

the State Agency on 10/01/25, revealed the following:1. An allegation of neglect where CNA #2 assisted R #2 to bed with a dirty (urine and bowel movement) adult brief on and did not assist with personal care that occurred on 09/30/25.2. An allegation of neglect where CNA #2 said R #3 refused his meal, but she never offered it to him on 09/30/25.C. On 11/21/25 at 9:20 am during an interview with the Administrator (ADM),

she confirmed that CNA #2 last worked at the facility on 09/28/25, indicating the date of incident was 09/28/25, not 09/30/25. The ADM confirmed both Initial Incident Reports (dated 10/06/25 and 09/30/25) were not submitted to the State Agency within the required timeframe.

Event ID:

Facility ID:

If continuation sheet

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

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Villa Healthcare

1515 South Sunset Avenue 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 F0610

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

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 3 (R #1, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are:A. Record review of the facility's Initial Incident Report dated 10/06/25 revealed an alleged incident of abuse where Certified Nurse Aide (CNA) yanked (pulled) R #1 by her left arm while assisting her into a sitting position which occurred on 10/03/25.B. Record review of the facility's investigation summary, no date, revealed the summary report was submitted to the State Survey Agency on 10/13/25 (six working days after the incident).C. Record

review of the facility's Initial Incident Report dated 10/02/25 revealed a resident-to-resident altercation where R #5 physically assaulted R #6. D. On 11/21/25 at 9:20 am during an interview with the Administrator (ADM), she confirmed the following:1. The facility's investigation summary for the incident regarding R #1 was not submitted within five working days.2. The facility failed to submit the investigation summary for the altercation between R #5 and R #6.

Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

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