Gallup, NM

Gallup Nursing & Rehabilitation LLC

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

Compare this facility

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

Facility snapshot

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

Hours and turnover

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

Value-based purchasing

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

How the VBP score is built

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

Medicare quality reporting measures

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

Resident outcomes and process scores

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

Recent inspection cycles

Cycle 1 Health 2024-10-10 · Fire 2024-10-10

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2023-06-16 · Fire 2023-06-16

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Cycle 3 Health 2022-03-17 · Fire 2022-03-17

27 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-10

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-11-10

F · Potential for more than minimal harm 2024-10-10

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-11-10

F · Potential for more than minimal harm 2024-10-10

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2024-11-10

F · Potential for more than minimal harm 2024-10-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-10

E · Potential for more than minimal harm 2024-10-10

K222 · Egress Deficiencies

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

E · Potential for more than minimal harm 2024-10-10

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-11-10

F · Potential for more than minimal harm 2023-06-16

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2023-07-21

F · Potential for more than minimal harm 2023-06-16

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2023-07-21

F · Potential for more than minimal harm 2023-06-16

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2023-07-21

F · Potential for more than minimal harm 2023-06-16

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-07-21

F · Potential for more than minimal harm 2023-06-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-07-21

E · Potential for more than minimal harm 2022-03-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-04-22

D · Potential for more than minimal harm 2022-03-17

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2022-04-29

Inspection history

Recent health citations

J · Immediate jeopardy 2024-12-18

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-28

D · Potential for more than minimal harm 2024-12-18

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-01-28

E · Potential for more than minimal harm 2024-10-10

F848 · Administration Deficiencies

Health

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected 2024-11-10

D · Potential for more than minimal harm 2024-10-10

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-11-10

D · Potential for more than minimal harm 2024-10-10

F655 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2024-10-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-11-10

F · Potential for more than minimal harm 2023-06-16

F761 · Pharmacy Service Deficiencies

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

F · Potential for more than minimal harm 2023-06-16

F812 · Nutrition and Dietary Deficiencies

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

F · Potential for more than minimal harm 2023-06-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-07-26

D · Potential for more than minimal harm 2023-06-16

F580 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2023-06-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-07-26

D · Potential for more than minimal harm 2023-06-16

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-07-26

D · Potential for more than minimal harm 2023-06-16

F688 · Quality of Life and Care Deficiencies

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

D · Potential for more than minimal harm 2023-06-16

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2023-07-26

F · Potential for more than minimal harm 2022-03-17

F812 · Nutrition and Dietary Deficiencies

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

F · Potential for more than minimal harm 2022-03-17

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2022-04-29

F · Potential for more than minimal harm 2022-03-17

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2022-04-29

E · Potential for more than minimal harm 2022-03-17

F578 · Resident Rights Deficiencies

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

E · Potential for more than minimal harm 2022-03-17

F741 · Quality of Life and Care Deficiencies

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

E · Potential for more than minimal harm 2022-03-17

F755 · Pharmacy Service Deficiencies

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

E · Potential for more than minimal harm 2022-03-17

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-04-29

E · Potential for more than minimal harm 2022-03-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-04-29

E · Potential for more than minimal harm 2022-03-17

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F564 · Resident Rights Deficiencies

Health

Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F623 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F625 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F655 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F656 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F688 · Quality of Life and Care Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-17

F758 · Pharmacy Service Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F806 · Nutrition and Dietary Deficiencies

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

D · Potential for more than minimal harm 2022-03-17

F842 · Resident Assessment and Care Planning Deficiencies

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

What sits behind the stars

Ownership

Garetz, David

Operational/Managerial Control · Individual

0% 58 facilities 2023-06-12
Garetz, David

Corporate Officer · Individual

0% 58 facilities 2023-06-12
Hansen Hunter LLC

Operational/Managerial Control · Organization

0% 37 facilities 2024-04-01

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