Paloma Springs Healthcare: Missing Drug Records - NM
The undocumented medications included anxiety medication hydroxyzine and an emergency albuterol nebulizer treatment administered to Resident #1 on April 13, 2025, according to state inspection records from Paloma Springs Healthcare LLC.
RN #1 told inspectors she gave the resident hydroxyzine at approximately 12:30 PM after the patient complained of shortness of breath and anxiety following lunch. The nurse said this wasn't uncommon for the resident, who had increased anxiety related to her COPD diagnosis.
She also administered a PRN albuterol nebulizer treatment around 4:00 PM when the resident again complained of breathing difficulties.
Neither medication appears on the facility's administration record for April 2025.
The resident's condition deteriorated throughout the day. By 4:53 PM, nursing notes show Resident #1 "has been short of breath throughout my shift, progressively worsening." Staff could not get her oxygen levels above 83-84 percent. Normal oxygen levels for most adults range from 95 to 100 percent.
The resident also developed crackles in both lower lung bases and increased weakness that evening. The primary care provider ordered immediate transport to the emergency room via ambulance.
But the medication administration record tells an incomplete story of the day's events.
RN #1 documented giving the resident a scheduled ipratropium-albuterol combination nebulizer treatment around 12:30 PM. She told inspectors she checked on the resident at 1:00 PM and the patient reported the medication had helped.
The nurse said she returned at 4:00 PM when the resident complained of shortness of breath again, prompting the undocumented albuterol treatment. At 4:45 PM, she found the resident still struggling to breathe with new weakness and contacted the on-call provider.
Records show other medication administration gaps throughout the resident's care. Staff gave acetaminophen for pain complaints on three separate occasions between April 12 and 13 but failed to document basic pain assessment details required by the resident's care plan.
Nursing notes lack documentation of pain quality, severity, onset, duration, or what made the pain better or worse when staff administered acetaminophen at 7:08 AM on April 12, 4:19 PM on April 12, and 4:53 AM on April 13.
The Director of Nursing confirmed multiple documentation failures during an interview with state inspectors on August 19, 2025.
RN #1 did not document her assessments of the resident throughout the day that prompted her to give PRN medications, the director said. Staff are expected to document all resident assessments.
The nurse also failed to document the administration of PRN medications she gave on April 13. Staff are expected to document all medications on the administration record when they are given.
Staff did not document pain characteristics as indicated on the resident's care plan, the director confirmed. Staff are expected to document at minimum the pain levels for which they are administering PRN pain medications.
The missing documentation creates gaps in the medical record during a critical period when the resident's respiratory status was declining. Without proper medication logs, subsequent caregivers would have no way to know what treatments had already been attempted or their effectiveness.
RN #1 told inspectors the resident's anxiety was related to her COPD diagnosis, which caused breathing difficulties. The nurse said she gave hydroxyzine to help decrease anxiety and help the resident breathe easier, followed by the scheduled nebulizer treatment.
After checking on the resident an hour later, RN #1 said the resident reported the medication had helped. But when breathing problems returned in the afternoon, the nurse gave another nebulizer treatment that never appeared in official records.
The documentation failures occurred during a 24-hour period when the resident received multiple medications for pain, anxiety, and breathing difficulties before ultimately requiring emergency transport.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paloma Springs Healthcare LLC from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Paloma Springs Healthcare LLC in T OR C, NM was cited for violations during a health inspection on August 19, 2025.
The nurse said this wasn't uncommon for the resident, who had increased anxiety related to her COPD diagnosis.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.