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
16
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
4
Tags cited more than once
Across separate surveys
9
Inspection & testing records
Of the citations on file

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

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

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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Which alerts

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

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.

This facility16NM median14National median11
Citations on file over three years, compared
MeasureCitations
This facility16
Median facility in NM14
Median facility nationally11

Survey history

Citations at each Life Safety survey
82023-0262024-0322025-02
Citations at each Life Safety survey
Survey dateCitations
February 2, 20238
March 6, 20246
February 6, 20252

Most-cited tags

Most-cited tags at this facility
K-02912K-07122K-03242K-02932K-05111K-07411K-02111K-03211
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0291Install emergency lighting that can last at least 1 1/2 hours.22024-03-06
K-0712Have simulated fire drills held at unexpected times.22025-02-06
K-0324Provide properly protected cooking facilities.22024-03-06
K-0293Have properly located and lighted "Exit" signs.22024-03-06
K-0511Have properly installed electrical wiring and gas equipment.12023-02-02
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.12025-02-06
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12024-03-06
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.12023-02-02

What the citations cover

Citations by CMS category
  • Egress Deficiencies 5
  • Miscellaneous Deficiencies 4
  • Smoke Deficiencies 4
  • Services Deficiencies 2
  • Other 1
Citations by CMS category
CategoryCitations
Egress Deficiencies5
Miscellaneous Deficiencies4
Smoke Deficiencies4
Services Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies1

Every citation on file

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

February 6, 2025 — 2 citations

Citations issued on February 6, 2025
TagWhat the surveyor checksStatus
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (March 8, 2025)
K-0741Have 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

Citations issued on March 6, 2024
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (April 3, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (April 3, 2024)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (April 3, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (April 3, 2024)
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.Deficient, Provider has date of correction (April 3, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (April 3, 2024)

February 2, 2023 — 8 citations

Citations issued on February 2, 2023
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (February 21, 2023)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (February 21, 2023)
K-0321Ensure 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-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (February 21, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (February 21, 2023)
K-0521Ensure 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-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (February 21, 2023)
K-0921Ensure 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.