11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Albuquerque, NM
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
10101 Lagrima De Oro Road NE, Albuquerque, NM
(505) 298-1231
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
74
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1991-03-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.70
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Program rank
2,725
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.09
Composite VBP score used to determine payment impact.
Payment multiplier
1.0018
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.41
Baseline 17.66% · Performance 17.53% · Measure score 8.41 · Achievement 8.41 · Improvement 1.43
Healthcare-associated infections
8.44
Baseline 5.07% · Performance 5.31% · Measure score 8.44 · Achievement 8.44 · Improvement 0
Total nurse turnover
1.23
Baseline 63.38% · Performance 58.67% · Measure score 1.23 · Achievement 1.23 · Improvement 0.72
Adjusted total nurse staffing
1.16
Baseline 3.98 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.02% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 179 · Observed rate 6.7% · Lower 95% interval 5.98% |
| Discharge to community | 67.25% |
50.57%
16.7 pts better
|
Better than the National Rate · Eligible stays 162 · Observed rate 62.35% · Lower 95% interval 59.31% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.61% |
95.27%
1.3 pts better
|
Numerator 114 · Denominator 118 |
| Falls with major injury | 0.85% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 118 |
| Discharge self-care score | 46.43% |
53.69%
7.3 pts worse
|
Numerator 39 · Denominator 84 |
| Discharge mobility score | 29.76% |
50.94%
21.2 pts worse
|
Numerator 25 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 4.24% |
2.29%
2 pts worse
|
Numerator 5 · Denominator 118 · Adjusted rate 4.15% |
| Healthcare-associated infections requiring hospitalization | 5.31% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 2.17% · Lower 95% interval 2.78% |
| Staff COVID-19 vaccination coverage | 5.81% |
8.2%
2.4 pts worse
|
Numerator 5 · Denominator 86 |
| Staff flu vaccination coverage | 28.48% |
42%
13.5 pts worse
|
Numerator 88 · Denominator 309 |
| Discharge function score | 38.1% |
56.45%
18.4 pts worse
|
Numerator 32 · Denominator 84 |
| Transfer of health information to provider | 92.16% |
95.95%
3.8 pts worse
|
Numerator 47 · Denominator 51 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 40 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 15.87% |
25.2%
9.3 pts worse
|
Numerator 10 · Denominator 63 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.4%
2.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.9% |
3.5%
0.6 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 5.7% · Q4 3.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
1.8%
2 pts worse
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 12.5% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
5.4%
3.7 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 17.2% · Q4 16.0% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
14.1%
12.4 pts worse
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 27.6% · Q3 34.5% · Q4 14.8% · 4Q avg 26.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
14.7%
5.4 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.3% · Q3 10.0% · Q4 14.3% · 4Q avg 9.3% · 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 | 26.5% |
15.8%
10.7 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
14.6%
1.9 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 10.3% · Q3 7.1% · Q4 25.9% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
0.9%
1.3 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 0.0% · Q4 3.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
20.6%
0.7 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 12.0% · Q3 17.7% · Q4 23.0% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.7%
1.4 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.5% · Q3 4.6% · Q4 5.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
86.6%
12.1 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 98.3% · Q3 99.0% · Q4 98.4% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
15.9%
3.9 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.1% · Q3 0.5% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
86.4%
10.8 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
21.3%
0.2 pts worse
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 23.2% · Expected 25.7% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-17
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-10-15
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-15
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-15
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-20
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-05-20
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-10
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-10
Health
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.
Corrected 2025-01-10
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-10
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-10
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-10
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 2025-01-10
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-01-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-10
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
Health
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.
Corrected 2023-11-17
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-17
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-05
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-05
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 2023-10-05
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-05
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-05
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-05
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-05
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-10-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-05
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-10-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-05
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-10-05
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-05
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-05
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 2023-03-27
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-27
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-05-29
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-03-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-07
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-06-07
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-06-07
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-07
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-06-07
Health
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.
Corrected 2022-06-07
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-07
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
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