Cycle 1
Health 2024-08-23 · Fire 2024-08-23
9 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Las Vegas, NM
The NM Behavioral Health Institute at Las Vegas
2-star overall rating with 2-star inspections with abuse icon flag with $18,353 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3695 Hot Springs Boulevard, Las Vegas, NM
(505) 454-2100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
176
Certified beds
Average residents
90
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-09-29
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
0.77
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,050
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.98
Baseline 37.33% · Performance 43.33% · Measure score 4.98 · Achievement 4.98 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.42 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 25.88% |
8.2%
17.7 pts better
|
Numerator 22 · Denominator 85 |
| Staff flu vaccination coverage | 72.84% |
42%
30.8 pts better
|
Numerator 59 · Denominator 81 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
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 0.9 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.6
0.4 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
97.4%
7.7 pts worse
|
93.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 88.2% · Q3 86.0% · Q4 90.8% · 4Q avg 89.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
98.7%
1 pts worse
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.5%
3.3 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.1% · Q3 5.8% · Q4 6.9% · 4Q avg 6.8% · 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 | 9.2% |
5.4%
3.8 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 12.9% · Q3 7.1% · Q4 6.9% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
14.1%
10.4 pts worse
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 25.9% · Q3 25.6% · Q4 23.0% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 44.6% |
14.7%
29.9 pts worse
|
16.7%
27.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 42.3% · Q3 44.4% · Q4 48.0% · 4Q avg 44.6% · 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 | 5.6% |
15.8%
10.2 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.1% · Q3 5.2% · Q4 8.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
14.6%
7.5 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.8% · Q3 5.6% · Q4 9.2% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
1.3%
1.7 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.2% · Q3 3.1% · Q4 2.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
0.9%
3.5 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.5% · Q3 5.8% · Q4 3.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.0% |
20.6%
11.6 pts better
|
19.8%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 11.5% · Q3 6.4% · Q4 7.4% · 4Q avg 9.0% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.7%
0.8 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 3.5% · Q3 4.7% · Q4 3.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
86.6%
36.6 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 50.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-21 · Fire 2023-07-21
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-04-08 · Fire 2022-04-08
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
K · Immediate jeopardy
2024-08-23
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-08-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-08-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-08-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-08-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-04
F · Potential for more than minimal harm
2023-07-21
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 2023-11-01
F · Potential for more than minimal harm
2023-07-21
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-01
F · Potential for more than minimal harm
2023-07-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-07-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-19
F · Potential for more than minimal harm
2022-04-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-26
F · Potential for more than minimal harm
2022-04-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-05-26
Inspection history
Recent health citations
G · Actual harm
2024-08-23
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 2024-10-04
F · Potential for more than minimal harm
2024-08-23
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 2024-10-04
E · Potential for more than minimal harm
2024-08-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-23
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 2024-10-04
E · Potential for more than minimal harm
2024-08-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-23
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-23
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-23
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 2024-10-04
D · Potential for more than minimal harm
2024-08-23
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 2024-10-04
E · Potential for more than minimal harm
2023-07-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-07-21
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 2023-08-10
D · Potential for more than minimal harm
2023-07-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-10
B · Minimal harm
2023-07-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-10
E · Potential for more than minimal harm
2022-04-08
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-07-13
E · Potential for more than minimal harm
2022-04-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-04-08
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 2022-07-13
D · Potential for more than minimal harm
2022-04-08
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-04-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-04-08
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 2022-07-13
D · Potential for more than minimal harm
2022-04-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-04-08
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 2022-07-13
D · Potential for more than minimal harm
2022-04-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-13
Penalties and ownership
What sits behind the stars
$18,353
2024-08-23
Fine
Fine · fine $18,353
Fine
$0
2024-08-23
Payment Denial
Payment Denial · denial start 2024-09-25 · 9 days
9 day denial
Ownership
Jaramillo, Charles
Operational/Managerial Control · Individual
Jaramillo, Charles
W-2 Managing Employee · Individual
Martinez, Darlene
W-2 Managing Employee · Individual
State Of New Mexico
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
La Vida Buena Healthcare
Las Vegas, NM
2-star overall rating with 1-star inspections with $96,079 in total fines with 34 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Santa Fe Care Center
Santa Fe, NM
1-star overall rating with 2-star inspections with $59,072 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Casa Real
Santa Fe, NM
0-star overall rating with 0-star inspections with Special Focus status with $350,027 in total fines with 32 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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