Home / New Mexico / Deming
Luna Wellness Rehabilitation, LLC
900 West Ash Street, Deming, NM 88030 · Luna County · (575) 299-2800
66 certified beds, about 47 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1992
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 325079 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 7, 2025, inspectors cited 9 health deficiencies (the New Mexico average is 17.9, the national average 9.2).
Of 55 health citations since December 2022, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 2 fines totaling $66,876 in the last three years; the largest was $50,905, and the latest is dated March 13, 2026.
Nurses and nurse aides worked 3.14 hours per resident per day, against 3.54 across New Mexico and 3.86 nationally. Registered nurses accounted for 0.49 of those hours.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
412/22
2301/24
403/24
407/24
904/25
309/25
803/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 55 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
19D
29E
4F
Potential for minimal harm
0A
0B
1C
March 13, 2026Complaint inspection · 8 citations
- E Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 2 (R #1 and R #3) of 3 (R #1, R #2 and R #3) residents reviewed for MDS timing. This deficient practice could likely result in residents' needs not being met.
- E Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident upon their admission to the facility) within 48 hours of admission for 2 (R #1 and R #2) of 3 (R #1, R #2 and R #3) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that may cause harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.
- E Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure there was a pressure injury risk assessment completed to determine the risk of developing a pressure ulcer (Injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) for 1 (R #10) of 1 (R #10) residents reviewed for pressure ulcers. This deficient practice could likely result in a delay in preventative measures and residents developing pressure ulcers.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 46 residents (residents were identified by the resident census list provided by the Administrator on 03/10/26). This deficient practice could likely result in residents not receiving the care and service needed while in the facility.
- E 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.
Inspectors wroteBased on observation and interview, the facility failed to secure medications in a medication cart for all 24 residents on North Hall (residents were identified by the census list provided by the DON on 05/12/26). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects.
- E Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #16, R #17, and R #24) of 3 (R #16, R #17, and R #24) residents reviewed for pressure ulcers when staff failed to: 1. Document wound care for R #16 and R 24. 2. Document medication administration for R #17. This deficient could likely cause staff to not have the most accurate resident information if the records are inaccurate or missing adversely impact the care staff provides.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS was accurate for 1 (R #17) of 3 (R #16, R #17, and R #24) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 1 (R #16) of 1 (R #16) residents reviewed for colostomy (a surgical procedure that creates an opening, called a stoma, in the abdominal wall. It connects the colon (large intestine) to the outside of your body, allowing stool to bypass a damaged or diseased part of the lower bowel and collect in an external, odor-proof pouch) care, when staff failed to: 1. Enter colostomy care orders upon admission for R #16's colostomy. 2. Provide colostomy care for R #16's colostomy. These deficient practices could likely lead to the residents not receiving the care needed and/or worsening of their medical conditions.
September 3, 2025Complaint inspection · 3 citations
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set Assessment was accurate for 1 (R #24) of 3 (R #16, R #17, and R #24) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plan revisions occurred for 2 (R #16 and R #24) of 3 (R #16, R #17, and R #24) residents reviewed for falls, when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
- D Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 2 (R #16, and R #24) of 3 (R #16, R #17, and R #24) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail.
April 7, 2025Standard inspection · 9 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to store food under sanitary conditions for all 33 residents (residents were identified by the resident census provided by the Administrator on 03/31/25) when staff failed to: 1. Label and date all items in the kitchen refrigerator. 2. Cover food in the refrigerator. Failure to store food under safe and sanitary conditions could likely to lead to foodborne illnesses in residents.
- E 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.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 3 (R #8, R #23, and R #24) of 5 (R #8, R #13, R #23, R #24, and R #25) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure that antidepressant medication for R #8 was prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Carry out a gradual dose reduction (GDR; [...]
- D 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.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #8 and R #13) of 2 (R #8 and R #12) residents reviewed for hospitalization. This deficient practice could likely result in the residents and/or their representative being unaware of the bed hold policy upon return from the hospital.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 1 (R #24) of 4 (R #11, R #15, R #24 and R #25) residents reviewed for accurate MDS assessments. If staff do not document accurately on the MDS assessment then the facility may not be aware of the residents needs.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #35) of 3 (R #8, R #13, and R #35) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #35) of 3 (R #24, R #25, and R #35) residents sampled for nutrition, when staff failed to follow protocols for identifying weight loss when R #35 had weight loss. This deficient practice could likely result in residents losing weight without the facility being aware of causing physical and mental health issues.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and the physician provided a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation for 2 (R #23 and R #24) of 5 (R #8, R #13, R #23, R #24, and R #25) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication).
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident medical records contained documentation that residents received, or staff offered the pneumococcal (a bacteria that caused pneumonia infection of the respiratory tract) vaccination for 1 (R #35) of 5 (R #9, R #15, R #23, R #25, and R #35) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis for access by the public and all 33 residents (residents were identified by the census list provided by the Administrator on 08/05/24), when staff failed to: 1. Post required staffing information. 2. Retain 18 months of posted staffing records. These deficient practices could likely prevent the public, as well as the residents from having access to accurate current and previous staffing records.
July 23, 2024Complaint inspection · 4 citations
- K Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to keep residents free from abuse for 6 (R #21, R #22, R #23, R #25, R #26, and R #27) of 6 (R #21, R #22, R #23, R #25, R #26, and R #27) residents sampled for abuse when staff failed to: 1. Implement interventions to prevent R #24 from touching R #21, R #23, R #25, and R #26 without consent. 2. Ensure R #24 did not enter R #25's room and R #27's personal space without permission while not fully clothed. 3. Ensure R #24 did not use sexually inappropriate comments when speaking to R #22. These deficient practices could likely result in physical harm to residents with inappropriate behaviors, physical harm and/or psychosocial distress (unpleasant emotions associated with a highly stressful situation) or worsening of current mental health conditions for the residents who were subject to this behavior.
- E Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to report allegations of abuse or neglect within two hours to the State Agency (SA) for 6 (R #21, R #22, R #23, R #25, R #26, and R #27) of 6 (R #21, R #22, R #23, R #25, R #26, and R #27) residents sampled for abuse. If the facility fails to report allegations of abuse or neglect to the SA within two hours, then residents could likely continue to be abused, suffer serious bodily injury, and/or experience in psychosocial distress (unpleasant emotions associated with a highly stressful situation) or worsening of current mental health conditions.
- E Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to have evidence that a thorough investigation of an allegation of abuse was conducted and preventive measures to keep residents safe were implemented for 6 (R #21, R #22, R #23, R #25, R #26, and R #27) of 6 (R #21, R #22, R #23, R #25, R #26, and R #27) residents sampled for abuse. These deficient practices could likely result in residents being at risk of continued abuse if allegations are not thoroughly investigated and preventative measures are not implemented.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to ensure care plan revision occurred for 2 (R #24 and R #31) of 3 (R #24, R #31, and R #32) residents when the staff failed to: 1. Revise R #24's care plan to include behavior of touching other residents without consent. 2. Revise R #24's care plan to include behavior of entering other residents rooms without consent. 3. Revise the care plan with the most current resident information for R #31. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
March 7, 2024Complaint inspection · 4 citations
- G Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide metal health services for 1 (R #1) of 2 (R #1 and R #2) residents sampled for abuse, when they failed to provide metal health services for R #1 after she alleged sexual abuse by a staff member providing care to her. This deficiency caused R #1 to have severe psycho-social distress having to deal with sexual abuse and past trauma brought on by the sexual abuse without mental health service.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, and interview, the facility failed to keep resident free from sexual abuse for 1 (R #1) of 2 (R #1 and R #2) residents sampled for abuse. This deficiency caused R #1 to have severe psycho-social distress having to deal with sexual abuse and past trauma brought on by the sexual abuse without mental health service.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to have evidence that a thorough investigation of an allegation of abuse was conducted and preventive measures to keep residents safe were implemented for 1 (R #1) of 2 (R #1, and R #2) residents sampled for abuse. This deficient practice could likely result in residents being at risk of continued abuse if allegations are not thoroughly investigated and preventative measures are not implement.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for (R #1) of 2 (R #1 and R #2) residents sampled for abuse. This deficient practice could likely result in staff being unaware of the needs of residents.
January 16, 2024Standard inspection · 23 citations
- F Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on interview and observation, the facility failed to post the results of the most recent state survey and make them accessible to residents and the public. This failure could affect all 39 residents in the facility (residents were identified by the Resident Matrix provided by the DON on 01/08/23). If residents are unable to review the latest survey conducted by State Surveyors, then residents, representatives, and visitors are likely unable to know how the facility is doing and make decisions accordingly.
- F Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview, the facility failed to designate a qualified, trained, or certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP.) This failure affected all 39 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 01/08/24). This deficient practice could likely result in residents being at greater risk of infectious disease.
- E Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to inform residents when changes in coverage were made to items and services covered by Medicare and/or by Medicaid for 2 (R #13 and 98) of 3 (R #13, R #38, and R #98) residents reviewed for beneficiary notices when they failed to provide R #13 and R #98 with Form CMS-10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage [form used to inform the beneficiary (resident) about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services.] This deficient practice can likely result in confusion for the resident or their representative as to what services they receive or do not have financial coverage for under Medicare and/or Medicaid.
- E Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff, which included the traditional care of the resident, the prevention and early detection of disease, and rehabilitation) was completed and accurate for 5 (R #16, R #17, R #27, R #38, and R #197) of 6 (R #15, R #16, R #17, R #27, R #38, and R #197) residents reviewed for completion of a comprehensive MDS assessment. When they failed to: 1. Complete an Annual MDS assessment for R #17 no less than once every 12 months. 2. Complete a Discharge MDS assessment for R #16, R #27, and R #38 within 14 days after discharge. 3. Complete an admission MDS assessment for R #197 within 14 calendar days after admission. These deficient practices could likely result in residents' preferences and needs not being met.
- E Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was completed every three months for 14 (R #2, R #7, R #9, R #10, R #12, R #19, R #22, R #26, R #31, R #34, R #35, R #36, R #38, and R #42) of 12 (R #2, R #7, R #9, R #10, R #12, R #19, R #22, R #26, R #31, R #34, R #35, R #36, R #38, and R #42) residents reviewed for quarterly MDS assessments. This failed practice is likely to result in resident assessments being outdated and residents not receiving care and treatment that meets their current needs.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #32) of 5 (R #2, R #15, R #26, R #31, and R #32) residents reviewed for comprehensive care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 1 (R #29) of 3 (R #26, R #29 and R #31) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
- E Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #31) of 3 (R #15, R #26, and R #31) residents reviewed for professional standards of care, when staff did not follow physician's orders. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication.
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 1 (R #25) of 2 (R #11 and R #25) residents reviewed for ADL care when they failed to assist R #25 with brushing her teeth and eating. This deficient practice is likely to affect the dignity and health of the residents.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 (R #4, R #9, and R #20) of 3 (R #4, R #9, and R #20) residents when they failed to: 1. Answer call lights in a timely manner for R #4 and R #9. 2. Complete skin assessments as ordered for R #20. This deficient practice could likely lead to residents needs not being met and/or a worsening of their condition. Call Lights R#4 A. On 01/10/24 at 2:13 PM, during an interview with resident council members, R #4 said sometimes it took around 30 minutes for staff to answer the call lights. B. Record review of R #4's Call Light History Log, dated 12/01/23 to 01/16/24, revealed the following: 1. On 12/05/23 at 6:30 AM, wait time of 31 minutes. 2. On 12/05/23 at 8:39 AM, wait time of 21 minutes. 3. [...]
- E 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.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease in range of motion for 2 (R #26 and R #29) of 3 (R #26, R #29 and R #41) residents reviewed for restorative therapy, when they failed to initiate a restorative nursing program (RNP; nursing service that often follows skilled rehabilitation services provided by physical or occupational therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions). This deficient practice could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own activities of daily living (ADLs).
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician or to ensure the physician provided rationale for not following the recommendation for 2 (R #8 and R #25) of 5 (R #2, R #8, R #9, R #25, and R #32) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions or adverse side effects.
- E Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to provide a drug regimen that was free from unnecessary medication by giving medication as ordered for 1 (R #29) of 1 (R #29) residents reviewed for unnecessary medication. This deficient practice could likely lead to R #29 receiving medication he doesn't need.
- E 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.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or diagnosis and was documented in the medical record for 2 (R #25 and R #32) of 3 (R #8, R #25 and R #32) residents reviewed for unnecessary psychotropic medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).
- E 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.
Inspectors wroteBased on observation and interview, the facility failed to properly store medications in the medication carts for all 39 residents (residents were identified by the resident matrix provided by the Administrator on 01/08/24) randomly sampled, when they failed to secure the medication carts on the East unit. This deficient practice could likely result in residents obtaining medication not prescribed to them and residents having adverse side effects.
- E Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents obtained routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments for 8 (R #2, R #11, R #15, R #25, R #26, R #29, R #31, and R #41) of 8 (R #2, R #11, R #15, R #25, R #26, R #29, R #31, and R #41) residents reviewed for dental services. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures when the did not ensure a waste receptacle for doffed (removed) personal protection equipment (PPE; clothing, gloves, face shields, goggles, facemasks, gowns and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) was available inside the room of residents on transmission-based precautions (TBP; residents who are known or suspected to be infected or colonized with infectious agents). Failure to adhere to an infection control program is likely to cause the spread of infections and illness to all 39 residents (residents were identified by the resident matrix provided by the DON on 01/08/24).
- E Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure each resident received or staff offered them the Influenza (the flu; an infection of the nose, throat, and lungs) immunization for 2 (R #11 and R # 41) of 6 (R #9, R #11, R #25, R #31, R# 36 and R #41) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents.
- E Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review, the facility failed ensure CNAs completed 12 hours of annual training that included dementia management training for 3 (CNA #1, CNA #2 and CNA #3) of 3 (CNA #1, CNA #2 and CNA #3) CNAs sampled for required annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care.
- E Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health (the emotions and behaviors that affect your overall well-being) training for 6 staff (CNA #1, CNA #2, CNA #3, LPN #1, LPN #11 and RN #1) of 6 (CNA #1, CNA #2, CNA #3, LPN #1, LPN #11 and RN #1) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to create a baseline care plan within 48 hours, that accurately reflected the resident's current condition for 1 (R #197) of 3 (R #9, R #8, and R #197) residents sampled for behavioral health services. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (an event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission.
- D Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed to ensure staff completed a discharge summary to include a recapitulation (a concise summary describing the resident's course of treatment while residing in the facility) and a medication reconciliation for 1 (R #16) of 1 (R #16) residents sampled for discharge from the facility. This deficient practice could likely lead to the resident, caregivers, and/or receiving home health agency not knowing what the current care needs and significant medical history are for the resident.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for the treatment of a urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder and urethra) for 1 (R #198) of 2 (R #31 and R #198) residents sampled for urinary tract infections, when they failed to administer antibiotics (medication used to treat bacterial infections) according to the physician orders. This deficient practice could likely result in prolonged symptoms and worsening of the Urinary Tract Infection.
December 7, 2022Standard inspection · 4 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety by not: 1. Ensuring food items in the dry pantry are labeled and dated, 2. Ensuring Food/food products are discarded by their expiration dates, 3. Ensure Dry Pantry's floor and shelves are clean and grime free, This deficient practice is likely to affect all 46 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 11/29/22), who eat food prepared in the kitchen. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, and interview, the facility failed to implement the comprehensive person-centered care plan developed for 1 (R #39) of 1 (R #39) residents reviewed for nutrition, when they failed to follow a Care Plan for weekly weights for R #39. This deficient practice could likely lead to residents going without the appropriate monitoring and not receiving the appropriate care and services to help maintain the highest practicable well-being.
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review, and interview, the facility failed to ensure residents, or their representatives received a written notice of transfer as soon as practicable for 1 (R #41) of 2 (R #41, and R #45) residents reviewed for discharge. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location that the resident was discharged .
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review, and interview, the facility failed to act upon the pharmacy recommendations for 1 (R #23) of 5 (R #6, R #23, R #35, R #41, and R #43) residents reviewed for unnecessary medications, when they failed to clarify R #23's order for Digoxin (is used to treat heart failure) indicating to hold the medication if the pulse is below 60. This deficient practice could likely result in residents receiving medications that may cause unnecessary drug interactions or adverse side effects.
Fire safety inspections
8 fire safety citations on file: 4 on January 16, 2024, 4 on December 7, 2022.
Every fire safety citation8 citations
- F Address patient/client population and determine types of services needed.
- F Address subsistence needs for staff and patients.
- F Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- C Inspect, test, and maintain automatic sprinkler systems.
- F Address patient/client population and determine types of services needed.
- F Address subsistence needs for staff and patients.
- E Install corridor and hallway doors that block smoke.
- E Have power receptacles that are properly grounded.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| March 13, 2026 | Payment Denial | 6 days from June 13, 2026 |
| July 23, 2024 | Fine | $50,905 |
| July 23, 2024 | Payment Denial | 9 days from August 27, 2024 |
| January 16, 2024 | Fine | $15,971 |
| January 16, 2024 | Payment Denial | 9 days from April 6, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | New Mexico | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.14 | 3.54 | 3.86 |
| Registered nurses | 0.49 | 0.63 | 0.69 |
| All nursing staff on weekends | 2.72 | 3.10 | 3.42 |
| Nurse aides | 1.63 | ||
| Licensed practical nurses | 1.02 | ||
| Nursing staff turnover (share who left in a year) | not reported | 53.3% | 45.8% |
| Registered nurse turnover | not reported | 53.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.29 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.31 on weekdays and 2.72 on weekends, 18% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.14 in April to June 2025 to 3.14 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.14 | 0.49 | 3.31 | 2.72 | 0.0% | 0 of 90 | 47 |
| Oct to Dec 2025 | 2.95 | 0.35 | 3.18 | 2.37 | 0.0% | 0 of 92 | 51 |
| Jul to Sep 2025 | 3.00 | 0.33 | 3.29 | 2.27 | 0.0% | 3 of 92 | 49 |
| Apr to Jun 2025 | 3.14 | 0.54 | 3.26 | 2.83 | 0.3% | 1 of 91 | 42 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| New Mexico, Jan to Mar 2026 | 3.52 | 0.60 | 3.69 | 3.10 | 14.2% | 1.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for New Mexico
| Job | Median | Middle half | Employed |
|---|---|---|---|
| New Mexico, all employers | |||
| CNAs (nursing assistants) | $18.94 | $17.94 to $21.83 | 4,750 |
| LPNs and LVNs | $28.52 | $18.93 to $35.14 | 2,460 |
| Registered nurses | $45.36 | $38.92 to $49.40 | 17,980 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | New Mexico | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 2.4 | 11.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.6 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.0 | 3.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.7 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 6.7 | 11.7 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.6 | 5.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 14.4 | 14.5 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 21.5 | 22.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 34.9 | 15.7 | 12.0 |
Owners and operators
Legal business name: LUNA WELLNESS & REHABILITATION LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Luna Operations Holdings LLC | Direct ownership interest | Organization | 04/01/2025 | |
| Blanca Peak LLC | Indirect ownership interest | Organization | 04/01/2025 | |
| Katz, Ahron | Indirect ownership interest | Individual | 04/01/2025 | |
| Greenberg, David | Operational/managerial control | Individual | 04/01/2025 | |
| Katz, Ahron | Operational/managerial control | Individual | 04/01/2025 | |
| Yanez, Carlos | Operational/managerial control | Individual | 05/15/2025 | |
| Greenberg, David | Adp of the SNF | Individual | 04/01/2025 | |
| Yanez, Carlos | Adp of the SNF | Individual | 05/15/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 19 problems in this area, most recently on March 13, 2026: "Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 9 problems in this area, most recently on March 13, 2026: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 8 problems in this area, most recently on March 13, 2026: "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."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 5 problems in this area, most recently on July 23, 2024: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.72 hours per resident per day, below the New Mexico average of 3.10.
New Mexico contacts for a concern about a nursing home
These are the official offices in New Mexico. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: New Mexico Health Care Authority, Division of Health Improvement, Health Facility Licensing and Certification, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: New Mexico Long-Term Care Ombudsman Program, Aging and Long-Term Services Department, 866-451-2901. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
Common questions
- What is Luna Wellness Rehabilitation, LLC's Medicare star rating?
- CMS rates Luna Wellness Rehabilitation, LLC 2 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Luna Wellness Rehabilitation, LLC get at its last inspection?
- 9 health deficiencies at the standard inspection on April 7, 2025. The New Mexico average is 17.9.
- Has Luna Wellness Rehabilitation, LLC been fined?
- Yes. CMS lists 2 fines totaling $66,876 in the last three years.
- Does Luna Wellness Rehabilitation, LLC accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Luna Wellness Rehabilitation, LLC?
- CMS lists 8 owners and managers. Legal business name: LUNA WELLNESS & REHABILITATION LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.