Cycle 1
Health 2024-07-02 · Fire 2024-07-02
25 health deficiencies
Top issue: Resident Assessment and Care Planning (9 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Las Cruces, NM
Las Cruces Wellness & Rehabilitation LLC
2-star overall rating with 2-star inspections with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
175 N Roadrunner Parkway, Las Cruces, NM
(575) 386-5800
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
2018-04-11
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
0.64
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
2.31
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
5.14
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
2.95
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.30
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,942
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.50% · Performance 26.09% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.05
Baseline 6.30% · Performance 6.33% · Measure score 5.05 · Achievement 5.05 · Improvement 0
Total nurse turnover
1.82
Baseline 73.33% · Performance 62.07% · Measure score 1.82 · Achievement 0 · Improvement 1.82
Adjusted total nurse staffing
0.55
Baseline 3.78 hours · Performance 3.23 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.38% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 458 · Observed rate 10.92% · Lower 95% interval 9.18% |
| Discharge to community | 60.94% |
50.57%
10.4 pts better
|
Better than the National Rate · Eligible stays 496 · Observed rate 57.26% · Lower 95% interval 56.1% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.37% |
95.27%
4.1 pts better
|
Numerator 316 · Denominator 318 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 3 · Denominator 318 |
| Discharge self-care score | 73.01% |
53.69%
19.3 pts better
|
Numerator 119 · Denominator 163 |
| Discharge mobility score | 65.03% |
50.94%
14.1 pts better
|
Numerator 106 · Denominator 163 |
| Pressure ulcers or injuries, new or worsened | 1.26% |
2.29%
1 pts better
|
Numerator 4 · Denominator 318 · Adjusted rate 1.42% |
| Healthcare-associated infections requiring hospitalization | 6.32% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 299 · Observed rate 5.02% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 14.15% |
8.2%
6 pts better
|
Numerator 15 · Denominator 106 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 74.23% |
56.45%
17.8 pts better
|
Numerator 121 · Denominator 163 |
| Transfer of health information to provider | 97.44% |
95.95%
1.5 pts better
|
Numerator 190 · Denominator 195 |
| Transfer of health information to patient | 95.8% |
96.28%
0.5 pts worse
|
Numerator 114 · Denominator 119 |
| Resident COVID-19 vaccinations up to date | 13.04% |
25.2%
12.2 pts worse
|
Numerator 21 · Denominator 161 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
86.6%
11.6 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 98.1% · Q3 99.1% · Q4 99.7% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
15.9%
1.8 pts better
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 13.7% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.8% |
86.4%
6.4 pts better
|
79.7%
13.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
21.3%
10 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 30.3% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-14 · Fire 2023-03-14
20 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-12-21 · Fire 2021-12-21
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-11
F · Potential for more than minimal harm
2024-07-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-11
F · Potential for more than minimal harm
2023-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-19
F · Potential for more than minimal harm
2023-03-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-11
F · Potential for more than minimal harm
2021-12-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-02-03
E · Potential for more than minimal harm
2021-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-02-03
E · Potential for more than minimal harm
2021-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-11-26
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 2025-12-31
D · Potential for more than minimal harm
2025-11-26
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 2025-12-31
E · Potential for more than minimal harm
2025-08-08
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 2025-10-31
E · Potential for more than minimal harm
2025-08-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-31
E · Potential for more than minimal harm
2025-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-03-18
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 2025-04-15
D · Potential for more than minimal harm
2025-03-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-18
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 2025-04-15
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-10
E · Potential for more than minimal harm
2024-07-02
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-08-10
E · Potential for more than minimal harm
2024-07-02
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-08-10
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
E · Potential for more than minimal harm
2024-07-02
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 2024-08-10
D · Potential for more than minimal harm
2024-07-02
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 2024-08-10
D · Potential for more than minimal harm
2024-07-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-10
C · Minimal harm
2024-07-02
F584 · Resident Rights Deficiencies
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 2024-08-10
E · Potential for more than minimal harm
2024-04-08
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-05-02
E · Potential for more than minimal harm
2023-10-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-01
G · Actual harm
2023-03-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-14
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 2023-04-24
E · Potential for more than minimal harm
2023-03-14
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 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
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 2023-04-24
E · Potential for more than minimal harm
2023-03-14
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 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F726 · Nursing and Physician Services Deficiencies
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 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
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 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-14
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-14
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 2023-04-24
D · Potential for more than minimal harm
2023-03-14
F756 · Pharmacy Service Deficiencies
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 2023-04-24
E · Potential for more than minimal harm
2021-12-21
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 2022-02-21
E · Potential for more than minimal harm
2021-12-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-02-21
E · Potential for more than minimal harm
2021-12-21
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 2022-02-21
E · Potential for more than minimal harm
2021-12-21
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-02-21
E · Potential for more than minimal harm
2021-12-21
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 2022-02-21
E · Potential for more than minimal harm
2021-12-21
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 2022-02-21
E · Potential for more than minimal harm
2021-12-21
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 2022-02-21
D · Potential for more than minimal harm
2021-12-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-02-21
D · Potential for more than minimal harm
2021-12-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-02-21
D · Potential for more than minimal harm
2021-12-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-02-21
D · Potential for more than minimal harm
2021-12-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-02-21
D · Potential for more than minimal harm
2021-12-21
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 2022-02-21
Penalties and ownership
What sits behind the stars
Ownership
Lc Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Garetz, David
5% Or Greater Indirect Ownership Interest · Individual
Garetz, David
Corporate Officer · Individual
Gurrocks Trust
5% Or Greater Indirect Ownership Interest · Organization
Lc Hcp LLC
5% Or Greater Indirect Ownership Interest · Organization
Lc Healthcare Holdings LLC
Operational/Managerial Control · Organization
Roach, Jennifer
W-2 Managing Employee · Individual
Sbd Trust
5% Or Greater Mortgage Interest · Organization
Zaffig Realty Trust
5% Or Greater Mortgage Interest · Organization
Zees K Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Calibre Post Acute, LLC
Las Cruces, NM
1-star overall rating with 1-star inspections with 32 recent health deficiencies
#2
Casa Del Sol Center
Las Cruces, NM
2-star overall rating with 3-star inspections with 27 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Northrise Wellness & Rehabilitation
Las Cruces, NM
3-star overall rating with 3-star inspections with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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