21 health deficiencies
Top issue: Resident Rights (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Roswell, NM
1-star overall rating with 1-star inspections with Special Focus status with $99,368 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1601 South Main Street, Roswell, NM
(575) 623-6008
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
118
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
1998-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.32
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
2.62
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.24
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Program rank
11,882
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.80% · Performance 26.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.89
Baseline 8.28% · Performance 7.50% · Measure score 1.89 · Achievement 1.13 · Improvement 1.89
Total nurse turnover
4.06
Baseline 75.00% · Performance 52.11% · Measure score 4.06 · Achievement 2.83 · Improvement 4.06
Adjusted total nurse staffing
0
Baseline 3.48 hours · Performance 2.91 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 16.34% |
10.72%
5.6 pts worse
|
Worse than the National Rate · Eligible stays 195 · Observed rate 21.54% · Lower 95% interval 12.11% |
| Discharge to community | 50.96% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 45.99% · Lower 95% interval 44.53% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 60.54% |
95.27%
34.7 pts worse
|
Numerator 89 · Denominator 147 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 147 |
| Discharge self-care score | 63% |
53.69%
9.3 pts better
|
Numerator 63 · Denominator 100 |
| Discharge mobility score | 64% |
50.94%
13.1 pts better
|
Numerator 64 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 147 · Adjusted rate 0.7% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 7.35% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 4.14% |
8.2%
4.1 pts worse
|
Numerator 7 · Denominator 169 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 66% |
56.45%
9.5 pts better
|
Numerator 66 · Denominator 100 |
| Transfer of health information to provider | 97.96% |
95.95%
2 pts better
|
Numerator 48 · Denominator 49 |
| Transfer of health information to patient | 87.69% |
96.28%
8.6 pts worse
|
Numerator 57 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 6.76% |
25.2%
18.4 pts worse
|
Numerator 5 · Denominator 74 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.6
0.2 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.4%
2.3 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.7%
1.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
3.5%
3.2 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
1.8%
1 pts worse
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 4.6% · Q4 2.8% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.4%
0.3 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.8% · Q3 2.8% · Q4 5.8% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
14.1%
1.1 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.9% · Q3 14.5% · Q4 15.7% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
14.7%
2.7 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 17.5% · Q3 11.3% · Q4 9.1% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.0% |
15.8%
6.2 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
14.6%
0.4 pts worse
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 15.6% · Q3 8.7% · Q4 6.3% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.3%
0.7 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.9%
0.9 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
20.6%
0.6 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 27.2% · Q3 20.7% · Q4 18.8% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.7%
3.8 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.4% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.2% |
86.6%
17.4 pts worse
|
81.7%
12.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.6% · Q2 59.8% · Q3 71.9% · Q4 88.1% · 4Q avg 69.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.5% |
15.9%
7.6 pts worse
|
12.0%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 22.7% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 2.1% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.2% |
86.4%
19.2 pts worse
|
79.7%
12.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
21.3%
1.3 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 18.9% · Expected 22.6% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Nursing and Physician Services (4 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-10-11
Fire Safety
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.
Corrected 2024-10-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-07
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-07
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-09-08
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-09-08
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-09-08
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-09-08
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-09-08
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-08
Fire Safety
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.
Corrected 2022-09-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-30
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-08
Inspection history
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-08
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-10-11
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-10-11
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-10-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-11
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-10-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-11
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-10-11
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-10-11
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-11
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-11
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-11
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-10-11
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-11
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-11
Health
Provide or obtain dental services for each resident.
Corrected 2024-10-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-11
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-10-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-11
Health
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.
Corrected 2024-09-11
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-05-08
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-05-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-19
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-19
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-24
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-24
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-08-07
Health
Post nurse staffing information every day.
Corrected 2023-08-07
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-08-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-07
Health
Dispose of garbage and refuse properly.
Corrected 2023-08-07
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-07
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-07
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-09-08
Health
Post nurse staffing information every day.
Corrected 2022-09-08
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2022-09-08
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-09-08
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-09-08
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-09-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-08
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-09-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-08
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-09-08
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-08
Health
Provide activities to meet all resident's needs.
Corrected 2022-09-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-08
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-09-08
Penalties and ownership
Fine · fine $36,895
Fine
Fine · fine $41,861
Fine
Fine · fine $20,612
Fine
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
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