Cycle 1
Health 2025-04-05 · Fire 2025-04-05
7 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Carlsbad, NM
Northgate Unit Of Lakeview Christian Home
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1905 West Pierce Street, Carlsbad, NM
(575) 885-3161
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-08-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.81
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,728
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.84% · Performance 21.66% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.70% · Performance 9.56% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.79
Baseline 40.84% · Performance 52.27% · Measure score 2.79 · Achievement 2.79 · Improvement 0
Adjusted total nurse staffing
3.43
Baseline 3.56 hours · Performance 4.05 hours · Measure score 3.43 · Achievement 3.43 · Improvement 1.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 8.33% · Lower 95% interval 6.76% |
| Discharge to community | 44.63% |
50.57%
5.9 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 37.68% · Lower 95% interval 36.34% |
| Medicare spending per beneficiary | 1.45 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 60 · Denominator 60 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 2 · Denominator 60 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 28 · Denominator 42 |
| Discharge mobility score | 54.76% |
50.94%
3.8 pts better
|
Numerator 23 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 5 · Denominator 60 · Adjusted rate 6.42% |
| Healthcare-associated infections requiring hospitalization | 9.56% |
7.12%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 14.29% · Lower 95% interval 5.3% |
| Staff COVID-19 vaccination coverage | 9.42% |
8.2%
1.2 pts better
|
Numerator 18 · Denominator 191 |
| Staff flu vaccination coverage | 4.74% |
42%
37.3 pts worse
|
Numerator 9 · Denominator 190 |
| Discharge function score | 69.05% |
56.45%
12.6 pts better
|
Numerator 29 · Denominator 42 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · 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 1.3 · Expected 1.4 · Used in QM five-star |
| 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 | 6.3% |
3.5%
2.8 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.3% · Q3 6.4% · Q4 9.2% · 4Q avg 6.3% · 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 | 3.3% |
5.4%
2.1 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 3.2% · Q4 6.9% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
14.1%
5.8 pts worse
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 17.2% · Q3 21.9% · Q4 21.7% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
14.7%
11.5 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.2% · Q3 3.8% · Q4 2.2% · 4Q avg 3.2% · 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 | 17.9% |
15.8%
2.1 pts worse
|
16.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 19.2% · Q3 7.3% · Q4 27.0% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
14.6%
5.1 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 23.3% · Q3 15.3% · Q4 14.0% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.3%
0.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
0.9%
2.8 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 2.6% · Q4 8.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
20.6%
5.3 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 13.2% · Q3 11.8% · Q4 19.9% · 4Q avg 15.3% |
| Percentage of long-stay residents with pressure ulcers | 11.7% |
5.7%
6 pts worse
|
5.1%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.0% · Q3 13.5% · Q4 11.3% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
86.6%
10.6 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
15.9%
4.4 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 11.8% · Expected 11.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
86.4%
9.9 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
21.3%
9.7 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 32.4% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-29 · Fire 2024-03-29
16 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-04-07 · Fire 2023-04-07
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-05
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 2025-05-20
E · Potential for more than minimal harm
2025-04-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-05-20
F · Potential for more than minimal harm
2024-03-29
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
K321 · Smoke Deficiencies
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-29
F · Potential for more than minimal harm
2023-04-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-07
F · Potential for more than minimal harm
2023-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-04-07
K321 · Smoke Deficiencies
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 2023-05-07
E · Potential for more than minimal harm
2023-04-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-07
E · Potential for more than minimal harm
2023-04-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-07
E · Potential for more than minimal harm
2023-04-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-07
E · Potential for more than minimal harm
2023-04-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-07
D · Potential for more than minimal harm
2023-04-07
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-05-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-27
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 2025-10-03
D · Potential for more than minimal harm
2025-08-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-04-05
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 2025-05-20
E · Potential for more than minimal harm
2025-04-05
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 2025-05-20
E · Potential for more than minimal harm
2025-04-05
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 2025-05-20
D · Potential for more than minimal harm
2025-04-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-05
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 2025-05-20
F · Potential for more than minimal harm
2024-03-29
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 2024-05-29
F · Potential for more than minimal harm
2024-03-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2024-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-03-29
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 2024-05-29
D · Potential for more than minimal harm
2024-03-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-29
C · Minimal harm
2024-03-29
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 2024-05-29
E · Potential for more than minimal harm
2023-04-07
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 2023-05-07
E · Potential for more than minimal harm
2023-04-07
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 2023-05-07
E · Potential for more than minimal harm
2023-04-07
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 2023-05-07
E · Potential for more than minimal harm
2023-04-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-07
E · Potential for more than minimal harm
2023-04-07
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 2023-05-07
E · Potential for more than minimal harm
2023-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-07
D · Potential for more than minimal harm
2023-04-07
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 2023-05-07
Penalties and ownership
What sits behind the stars
Ownership
Deines, Timothy
Corporate Director · Individual
Knox, Joanna
Operational/Managerial Control · Individual
Knox, Joanna
Corporate Director · Individual
Ross, James
Corporate Officer · Individual
Sevcik, Denise
Corporate Officer · Individual
Wood, Alan
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Artesia Healthcare & Rehabilitation Center, LLC
Artesia, NM
1-star overall rating with 2-star inspections with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Lovington Healthcare LLC
Lovington, NM
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
White Sands Healthcare
Hobbs, NM
2-star overall rating with 2-star inspections with abuse icon flag with $33,120 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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