D
Sunset Villa Healthcare
37/100 score
0.54 hrs RN staffing
17 deficiencies
Spring River Rehabilitation and Care Center
3200 Mission Arch Drive, Roswell, NM 88201
F
Facility Assessment
Inspectors recorded 1 citation at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — review inspection history before visiting.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.51 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
60
Outstanding
0
Actual harm or worse (G–L)
1
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★☆☆☆☆ (1/5)
Staffing: ★★☆☆☆ (2/5)
|
|
NursingHomeGrade Score
|
25/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
1 actual harm issue found among 60 total deficiencies. 60 corrected.
Most recent inspection (December 12, 2024)
F
Potential harm — widespread
F0865
Status: Corrected
Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
D
Potential harm — isolated
F0919
Status: Corrected
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected September 2, 2025
D
Potential harm — isolated
F0604
Status: Corrected
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
F
Potential harm — widespread
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
F
Potential harm — widespread
F0881
Status: Corrected
Implement a program that monitors antibiotic use.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0883
Status: Corrected
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0887
Status: Corrected
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
C
No harm — widespread
F0732
Status: Corrected
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
F
Potential harm — widespread
F0802
Status: Corrected
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
F
Potential harm — widespread
F0756
Status: Corrected
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
D
Potential harm — isolated
F0757
Status: Corrected
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0761
Status: Corrected
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0657
Status: Corrected
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
D
Potential harm — isolated
F0627
Status: Corrected
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 2, 2025
Inspection cycle 2 (September 6, 2024)
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
D
Potential harm — isolated
F0610
Status: Corrected
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
E
Potential harm — pattern
F0947
Status: Corrected
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
F
Potential harm — widespread
F0761
Status: Corrected
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
E
Potential harm — pattern
F0758
Status: Corrected
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
E
Potential harm — pattern
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
F
Potential harm — widespread
F0761
Status: Corrected
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
E
Potential harm — pattern
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
G
Actual harm — isolated
F0692
Status: Corrected
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0679
Status: Corrected
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
E
Potential harm — pattern
F0685
Status: Corrected
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
D
Potential harm — isolated
F0695
Status: Corrected
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2025
E
Potential harm — pattern
F0842
Status: Corrected
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2025
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
E
Potential harm — pattern
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2025
D
Potential harm — isolated
F0655
Status: Corrected
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
E
Potential harm — pattern
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
E
Potential harm — pattern
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
D
Potential harm — isolated
F0842
Status: Corrected
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
D
Potential harm — isolated
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
D
Potential harm — isolated
F0657
Status: Corrected
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
D
Potential harm — isolated
F0580
Status: Corrected
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2025
E
Potential harm — pattern
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2024
D
Potential harm — isolated
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
E
Potential harm — pattern
F0565
Status: Corrected
Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024
Inspection cycle 3 (November 18, 2022)
D
Potential harm — isolated
F0883
Status: Corrected
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
E
Potential harm — pattern
F0804
Status: Corrected
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
E
Potential harm — pattern
F0761
Status: Corrected
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected December 5, 2023
D
Potential harm — isolated
F0676
Status: Corrected
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
D
Potential harm — isolated
F0692
Status: Corrected
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
E
Potential harm — pattern
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
E
Potential harm — pattern
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
D
Potential harm — isolated
F0567
Status: Corrected
Honor the resident's right to manage his or her financial affairs.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 13, 2024
D
Potential harm — isolated
F0584
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2022
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F
Casa Maria Healthcare
14/100 score
0.32 hrs RN staffing
21 deficiencies
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