Cycle 1
Health 2025-01-30 · Fire 2025-01-30
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Las Cruces, NM
Northrise Wellness & Rehabilitation
3-star overall rating with 3-star inspections with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2884 North Road Runner Parkway, Las Cruces, NM
(575) 522-1110
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
31
Certified beds
Average residents
24
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
2001-01-08
CMS approved date
Coverage
Medicare
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
Hours and turnover
RN hours / resident day
1.32
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.83
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
6.19
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
3.14
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
4.92
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
5.13
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,751
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.88% · Performance 24.07% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.61% · Performance 7.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 63.89% · Performance 66.67% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.28
Performance 4.29 hours · Measure score 4.28 · Achievement 4.28 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 269 · Observed rate 10.78% · Lower 95% interval 8.47% |
| Discharge to community | 60.73% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 263 · Observed rate 57.41% · Lower 95% interval 55.48% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 48.31% |
95.27%
47 pts worse
|
Numerator 86 · Denominator 178 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 178 |
| Discharge self-care score | 48.91% |
53.69%
4.8 pts worse
|
Numerator 45 · Denominator 92 |
| Discharge mobility score | 31.52% |
50.94%
19.4 pts worse
|
Numerator 29 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 0.56% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 178 · Adjusted rate 0.48% |
| Healthcare-associated infections requiring hospitalization | 7.96% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 141 · Observed rate 7.8% · Lower 95% interval 5.21% |
| Staff COVID-19 vaccination coverage | 7.32% |
8.2%
0.9 pts worse
|
Numerator 6 · Denominator 82 |
| Staff flu vaccination coverage | 80.18% |
42%
38.2 pts better
|
Numerator 178 · Denominator 222 |
| Discharge function score | 44.57% |
56.45%
11.9 pts worse
|
Numerator 41 · Denominator 92 |
| Transfer of health information to provider | 70.67% |
95.95%
25.3 pts worse
|
Numerator 53 · Denominator 75 |
| Transfer of health information to patient | 92.16% |
96.28%
4.1 pts worse
|
Numerator 94 · Denominator 102 |
| Resident COVID-19 vaccinations up to date | 21.74% |
25.2%
3.5 pts worse
|
Numerator 20 · Denominator 92 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
86.6%
1.7 pts worse
|
81.7%
3.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.6% · Q2 81.6% · Q3 87.5% · Q4 91.1% · 4Q avg 84.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
15.9%
0.7 pts better
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 15.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.2% · Q3 1.8% · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
86.4%
6.8 pts worse
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
21.3%
8.5 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 30.7% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-06 · Fire 2023-11-06
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
15 health deficiencies
Top issue: Resident Rights (6 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-11
F · Potential for more than minimal harm
2025-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-11
F · Potential for more than minimal harm
2023-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-11
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 2025-04-07
D · Potential for more than minimal harm
2025-12-11
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 2026-01-07
F · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
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 2025-04-21
E · Potential for more than minimal harm
2025-01-30
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-01-30
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 2025-04-21
D · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-01-30
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 2025-04-21
C · Minimal harm
2025-01-30
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 2025-04-21
C · Minimal harm
2025-01-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-21
E · Potential for more than minimal harm
2024-05-01
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-06-05
E · Potential for more than minimal harm
2023-11-06
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 2023-12-21
E · Potential for more than minimal harm
2023-11-06
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 2023-12-21
E · Potential for more than minimal harm
2023-11-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-11-06
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 2023-12-21
E · Potential for more than minimal harm
2023-11-06
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 2023-12-21
E · Potential for more than minimal harm
2023-11-06
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 2023-12-21
E · Potential for more than minimal harm
2023-11-06
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-11-06
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 2023-12-21
E · Potential for more than minimal harm
2023-11-06
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 2023-12-21
E · Potential for more than minimal harm
2023-11-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-11-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-11-06
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-11-06
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 2023-12-21
D · Potential for more than minimal harm
2023-11-06
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 2023-12-21
D · Potential for more than minimal harm
2023-11-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-11-06
F693 · Quality of Life and Care Deficiencies
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 2023-12-21
D · Potential for more than minimal harm
2023-11-06
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 2023-12-21
D · Potential for more than minimal harm
2023-11-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-01-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-01-12
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 2023-03-24
E · Potential for more than minimal harm
2023-01-12
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 2023-03-24
E · Potential for more than minimal harm
2023-01-12
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-01-12
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 2023-03-24
E · Potential for more than minimal harm
2023-01-12
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 2023-03-24
E · Potential for more than minimal harm
2023-01-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-01-12
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 2023-03-24
E · Potential for more than minimal harm
2023-01-12
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-01-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-01-12
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 2023-03-24
D · Potential for more than minimal harm
2023-01-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-01-12
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 2023-03-24
D · Potential for more than minimal harm
2023-01-12
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 2023-03-24
Penalties and ownership
What sits behind the stars
Ownership
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
Las Cruces Wellness & Rehabilitation LLC
Las Cruces, NM
2-star overall rating with 2-star inspections with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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
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