Sunset Villa Healthcare
1515 South Sunset Avenue, Roswell, NM 88203 · Chaves County · 52 certified beds · avg 50 residents/day · certified since Apr 23, 2004
Abuse citation flag (CMS)
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 6, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 2, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jun 7, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 5, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Mar 6, 2024 · F-0740
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 3, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 6, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 3, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 6, 2024 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 3, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (55)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 23, 2026 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 23, 2026 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 23, 2026 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Nov 21, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Nov 21, 2025 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 21, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 2, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Feb 6, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 6, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 6, 2025 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Feb 6, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 6, 2025 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 6, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 6, 2025 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Feb 6, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Feb 6, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 6, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 6, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 6, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Feb 6, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 7, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 7, 2024 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jun 7, 2024 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jun 7, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 6, 2024 | ▲ H · Actual harm, repeated | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Mar 6, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 6, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Mar 6, 2024 | F · Potential for harm, facility-wide | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| Mar 6, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 6, 2024 | F · Potential for harm, facility-wide | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
| Mar 6, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (13 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 31 | 4 | H ▲ |
| 2025 | 17 | 1 | G ▲ |
| 2026 | 7 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $80,968.
| Date | Type | Amount / length |
|---|---|---|
| Jun 7, 2024 | Fine | $48,109 |
| Mar 6, 2024 | Fine | $32,859 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | New Mexico avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.50 | 3.94 | 3.95 | bottom 27% in New Mexico; bottom 36% in the U.S. |
| Registered Nurse hours | 0.81 | 0.70 | 0.69 | top 30% in New Mexico; top 26% in the U.S. |
| Weekend total nurse staffing | 3.31 | 3.46 | 3.50 | top 50% in New Mexico; bottom 48% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.68 | 0.46 | 0.48 | top 18% in New Mexico; top 17% in the U.S. |
| Total nursing staff turnover (%) | 53.4 | 53.3 | 45.8 | bottom 48% in New Mexico; bottom 28% in the U.S. |
| RN turnover (%) | 33.3 | 53.6 | 42.9 | top 17% in New Mexico; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.43, RN 0.80, weekend 3.25. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Caliber Advisors LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2023 |
| Casa Healthcare, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 03/01/2023 |
| First Sweetzer Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2023 |
| Hatteras Investments LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2023 |
| 1515 S Sunset Ave NM, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Casa Healthcare, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2023 |
| Continuum Rehab Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Garetz, David | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2023 |
| Garetz, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2023 |
| Gurwitz, Solomon | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Hagins, Elizabeth | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Hallmark Advisors, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Hansen Hunter LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Kaplan, Esther | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Kaplan, Mosha | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Mindle, Adam | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Opco Ca Skilled Mgmt INC. | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Opco NM Skilled Mgmt, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Roy, Amanda | Individual | ADP of the SNF | NOT APPLICABLE | 05/13/2024 |
| Sternshein, Jennifer | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What mental health services do you provide on-site, and who delivers them?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Casa Maria Healthcare | 1.2 mi | Roswell, NM | ★☆☆☆☆ | 1/5 | |
| Spring River Rehabilitation and Care Center | 4.5 mi | Roswell, NM | ★☆☆☆☆ | 1/5 | SFF |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 325117.