Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Casa Maria Healthcare

Roswell, NM · 118 certified beds · Last Life Safety survey September 20, 2024

CMS Certification Number 325086 · first certified March 1998

Ownership

Operated by OPCO SKILLED MANAGEMENT · For profit - Limited Liability company

Ownership changed March 21, 2023 (change of ownership)from CASA MARIA OF NEW MEXICO, LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NM

17 citations — more than 61% of the 68 certified nursing homes in NM. Compared within NM rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (October 2025 to December 2025), and past the point by which nine in ten NM facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in NM are typically surveyed 13–15 months after the last one (median 14), measured over 65 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

7 of the 17 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in NM, and nationally. Surveyors differ markedly between states, so the NM figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	17
Median facility in NM	14
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 10, 2022	10
July 7, 2023	2
September 20, 2024	5

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0324	Provide properly protected cooking facilities.	2	2024-09-20
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-09-20
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	2	2024-09-20
E-0023	Establish policies and procedures for medical documentation.	1	2022-08-10
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	1	2022-08-10
E-0036	Establish emergency prep training and testing.	1	2022-08-10
E-0037	Establish staff and initial training requirements.	1	2022-08-10
K-0363	Install corridor and hallway doors that block smoke.	1	2022-08-10

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 7
Smoke Deficiencies 5
Egress Deficiencies 2
Gas, Vacuum, and Electrical Systems Deficiencies 2
Other 1

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	7
Smoke Deficiencies	5
Egress Deficiencies	2
Gas, Vacuum, and Electrical Systems Deficiencies	2
Services Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 20, 2024 — 5 citations

Citations issued on September 20, 2024
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (October 11, 2024)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (October 11, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 11, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 11, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 11, 2024)

July 7, 2023 — 2 citations

Citations issued on July 7, 2023
Tag	What the surveyor checks	Status
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 7, 2023)
K-0500	Meet other general requirements that are deficient.	Deficient, Provider has date of correction (August 7, 2023)

August 10, 2022 — 10 citations

Citations issued on August 10, 2022
Tag	What the surveyor checks	Status
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (September 8, 2022)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (September 8, 2022)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (September 8, 2022)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (September 8, 2022)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (September 8, 2022)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (September 8, 2022)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (September 8, 2022)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (September 8, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (September 8, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 30, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.