Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Sunset Villa Healthcare
Roswell, NM · 52 certified beds · Last Life Safety survey February 6, 2025
CMS Certification Number 325117 · first certified April 2004
Ownership
Operated by OPCO SKILLED MANAGEMENT · For profit - Corporation
- Ownership changed March 21, 2023 (change of ownership)from THI OF NEW MEXICO AT SUNSET VILLA, LLC
Position within NM
16 citations — more than 58% 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
The latest survey found 2 citations; the earlier surveys in the window averaged 7. 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 (March 2026 to May 2026), and past the point by which nine in ten NM facilities have been surveyed. This facility’s last Life Safety survey was February 2025. 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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3 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.
Physical environment (health survey)
7 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 16 Life Safety citations above. The Physical Environment Index
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in NM, and nationally. Surveyors differ markedly between states, so the NM figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 16 |
| Median facility in NM | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 2, 2023 | 8 |
| March 6, 2024 | 6 |
| February 6, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2024-03-06 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-02-06 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-03-06 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2024-03-06 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-02-02 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2025-02-06 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2024-03-06 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-02-02 |
What the citations cover
- Egress Deficiencies 5
- Miscellaneous Deficiencies 4
- Smoke Deficiencies 4
- Services Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Egress Deficiencies | 5 |
| Miscellaneous Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Services Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 6, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 8, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 8, 2025) |
March 6, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 3, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 3, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 3, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 3, 2024) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (April 3, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 3, 2024) |
February 2, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (February 21, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (February 21, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 21, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 21, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (February 21, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (February 21, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 21, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (February 21, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.