4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Gallup, NM
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
306 East Nizhoni Blvd, Gallup, NM
(505) 863-9551
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
62
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
2008-07-11
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
0.82
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.20
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Program rank
9,679
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.06
Baseline 18.45% · Performance 20.94% · Measure score 1.06 · Achievement 1.06 · Improvement 0
Healthcare-associated infections
5.73
Baseline 5.89% · Performance 6.12% · Measure score 5.73 · Achievement 5.73 · Improvement 0
Total nurse turnover
1.07
Baseline 58.62% · Performance 59.32% · Measure score 1.07 · Achievement 1.07 · Improvement 0
Adjusted total nurse staffing
1.30
Baseline 3.40 hours · Performance 3.45 hours · Measure score 1.30 · Achievement 1.30 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.83% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 16.52% · Lower 95% interval 8.11% |
| Discharge to community | 52.77% |
50.57%
2.2 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 44.21% · Lower 95% interval 40.28% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 100 · Denominator 104 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 71.01% |
53.69%
17.3 pts better
|
Numerator 49 · Denominator 69 |
| Discharge mobility score | 37.68% |
50.94%
13.3 pts worse
|
Numerator 26 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 4 · Denominator 102 · Adjusted rate 4.1% |
| Healthcare-associated infections requiring hospitalization | 6.12% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 4% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 6.06% |
8.2%
2.1 pts worse
|
Numerator 6 · Denominator 99 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 62.32% |
56.45%
5.9 pts better
|
Numerator 43 · Denominator 69 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| Transfer of health information to patient | 98.21% |
96.28%
1.9 pts better
|
Numerator 55 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 98.15% |
25.2%
73 pts better
|
Numerator 53 · Denominator 54 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.6
1.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
97.4%
1.5 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.3% · 4Q avg 98.9% |
| 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 | 4.3% |
3.5%
0.8 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 4.3% · Q4 4.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.8%
1.8 pts better
|
11.4%
11.4 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 who lose too much weight | 3.9% |
5.4%
1.5 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 7.7% · Q3 2.6% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.9% |
14.1%
12.2 pts better
|
19.6%
17.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.6% · Q4 2.7% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
14.7%
4 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 4.3% · Q3 14.3% · Q4 12.0% · 4Q avg 10.7% · 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 | 13.7% |
15.8%
2.1 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 25.8% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
14.6%
5.9 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 15.4% · Q3 0.0% · Q4 2.8% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.3%
0.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.1% · 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 | 20.7% |
20.6%
0.1 pts worse
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 21.4% · Q3 15.2% · Q4 28.7% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.7%
0.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.1% · Q3 7.6% · Q4 5.5% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
86.6%
9.2 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 96.2% · Q3 97.2% · Q4 97.8% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
15.9%
11.7 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
86.4%
0.8 pts worse
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
21.3%
1.2 pts worse
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 23.5% · Expected 25.0% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-10
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-10
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-11-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-10
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 2024-11-10
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-10
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-21
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-07-21
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-07-21
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-07-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-21
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-04-22
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-04-29
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-28
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-11-10
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-10
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-10
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-10
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 2023-07-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-26
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-26
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-26
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-26
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-07-26
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-07-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-29
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-04-29
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-04-29
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 2022-04-29
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2022-04-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-04-29
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-04-29
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-29
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-04-29
Health
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Corrected 2022-04-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-04-29
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-04-29
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-04-29
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-04-29
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-04-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-04-29
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-04-29
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-29
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-04-29
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-04-29
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-04-29
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 2022-04-29
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-04-29
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-29
Penalties and ownership
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Nearby options
Gallup, NM
4-star overall rating with 4-star inspections with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Grants, NM
5-star overall rating with 5-star inspections with $56,641 in total fines with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Chinle, AZ
1-star overall rating with 1-star inspections with Special Focus status with $127,634 in total fines with 17 recent health deficiencies
Jump out