Cycle 1
Health 2024-12-12 · Fire 2024-12-12
19 health deficiencies
Top issue: Infection Control (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Roswell, NM
Spring River Rehabilitation and Care Center
1-star overall rating with 2-star inspections with $34,398 in total fines with 19 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3200 Mission Arch Drive, Roswell, NM
(575) 624-2583
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1985-12-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing
LPN hours / resident day
0.80
Licensed practical nurse staffing
Aide hours / resident day
1.98
Nurse aide staffing
Weekend hours
3.01
Weekend nurse staffing
RN turnover
62%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover
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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.6
0.6 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
97.4%
0.4 pts worse
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
98.7%
0.9 pts worse
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.5%
0.7 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
1.8%
1.4 pts worse
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.4%
0.1 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
14.1%
0.2 pts worse
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
14.7%
3.7 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.0%
0.3 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.1% |
15.8%
22.3 pts worse
|
16.3%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.7% |
14.6%
21.1 pts worse
|
14.9%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.3%
0.4 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.9%
About the same
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
20.6%
3.1 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.7%
0.7 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
86.6%
8.6 pts worse
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.5% |
15.9%
12.6 pts worse
|
12.0%
16.5 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.3%
2.5 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.1% |
86.4%
23.3 pts worse
|
79.7%
16.6 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
21.3%
8.8 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
29 health deficiencies
Top issue: Resident Assessment and Care Planning (12 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-02-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-02-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-19
E · Potential for more than minimal harm
2022-11-18
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 2022-12-30
E · Potential for more than minimal harm
2022-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-18
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 2022-12-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-06
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-08-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-09-02
E · Potential for more than minimal harm
2025-02-07
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 2025-02-19
D · Potential for more than minimal harm
2025-02-07
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 2025-02-19
D · Potential for more than minimal harm
2025-02-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-19
F · Potential for more than minimal harm
2024-12-12
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 2025-02-05
F · Potential for more than minimal harm
2024-12-12
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-12-12
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-12-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-12
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 2025-02-05
E · Potential for more than minimal harm
2024-12-12
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 2025-02-05
E · Potential for more than minimal harm
2024-12-12
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 2025-02-05
E · Potential for more than minimal harm
2024-12-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-12
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 2025-02-05
E · Potential for more than minimal harm
2024-12-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-12
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-12
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 2025-02-05
D · Potential for more than minimal harm
2024-12-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-05
C · Minimal harm
2024-12-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-02-05
G · Actual harm
2024-11-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-11-15
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 2025-02-05
E · Potential for more than minimal harm
2024-11-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-09-06
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 2024-11-19
E · Potential for more than minimal harm
2024-09-06
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 2024-11-19
E · Potential for more than minimal harm
2024-09-06
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 2024-11-19
E · Potential for more than minimal harm
2024-09-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-09-06
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-09-06
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 2024-11-19
D · Potential for more than minimal harm
2024-09-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-09-06
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 2024-11-19
D · Potential for more than minimal harm
2024-09-06
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 2024-11-19
F · Potential for more than minimal harm
2024-02-09
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 2024-03-19
E · Potential for more than minimal harm
2024-02-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-09
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 2024-03-19
E · Potential for more than minimal harm
2024-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-09
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 2024-03-19
D · Potential for more than minimal harm
2024-02-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-09
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 2024-03-19
D · Potential for more than minimal harm
2024-02-09
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 2024-03-19
D · Potential for more than minimal harm
2024-02-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-09
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 2023-12-05
D · Potential for more than minimal harm
2024-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-19
D · Potential for more than minimal harm
2023-12-21
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-02-13
E · Potential for more than minimal harm
2022-11-18
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 2022-12-30
E · Potential for more than minimal harm
2022-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-18
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 2022-12-30
E · Potential for more than minimal harm
2022-11-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-18
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 2022-12-30
D · Potential for more than minimal harm
2022-11-18
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 2022-12-30
D · Potential for more than minimal harm
2022-11-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-30
Penalties and ownership
What sits behind the stars
$34,398
2024-11-15
Fine
Fine · fine $34,398
Fine
Ownership
Peak Medical LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Morris, Diane
Operational/Managerial Control · Individual
Perryman-Johnson, Carolyn
Operational/Managerial Control · Individual
Stolarczyk, Lisa
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sunbridge Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Casa Maria Healthcare
Roswell, NM
1-star overall rating with 1-star inspections with Special Focus status with $99,368 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Sunset Villa Healthcare
Roswell, NM
2-star overall rating with 2-star inspections with abuse icon flag with $80,968 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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
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