Paloma Springs Healthcare: Medication Records Failures - NM
The patient, identified in inspection records only as Resident 1, had a known history of anxiety tied to her COPD, a chronic lung disease that makes breathing difficult. The day shift nurse, RN #1, told inspectors she first saw the resident complain of shortness of breath and anxiety after lunch, around 12:30 p.m. She gave the resident hydroxyzine, an anti-anxiety medication, and the resident's scheduled nebulizer treatment, a combination bronchodilator that opens the airways. When she checked back around 1:00 p.m., the resident said the medication had helped.
It did not last.
By 4:00 p.m., Resident 1 was short of breath again. RN #1 gave her an additional albuterol nebulizer treatment, a second unscheduled intervention for the same complaint in the same afternoon. When the nurse checked again at 4:45 p.m., the resident was still short of breath and had developed increased weakness. RN #1 called the on-call provider, who ordered the resident sent to the emergency room by ambulance.
None of the afternoon's interventions appeared in the medication administration record. Not the 12:30 p.m. hydroxyzine. Not the 4:00 p.m. albuterol treatment. Not the assessments that led RN #1 to decide, twice, that the situation warranted medication.
The director of nursing confirmed each gap when inspectors interviewed her on August 19. RN #1 did not document her assessments. RN #1 did not document the hydroxyzine. RN #1 did not document the albuterol. Staff are expected to document all medications when given, the director said. Staff are expected to document all assessments. Neither happened.
The documentation failures did not begin on April 13. Inspection records show that on April 12, staff gave Resident 1 acetaminophen for pain three times — at 7:08 a.m., at 4:19 p.m., and again the following morning at 4:53 a.m. — without documenting the quality, severity, onset, duration, or aggravating and relieving factors of her pain. The resident's care plan required at minimum that pain levels be recorded when pain medication was administered. They were not.
What inspectors found when they reviewed the emergency room record added weight to what the missing documentation could not explain. Resident 1 arrived at the hospital with an oxygen saturation of 88 percent, a level that indicates the blood is not receiving adequate oxygen. Crackles were audible in both lower lung bases, an abnormal breath sound associated with respiratory disease. She also had increased weakness.
The inspection was triggered by a complaint and conducted on August 19, more than four months after the April events. By then, the afternoon of April 13 existed almost entirely in RN #1's recollection, offered during an interview at 11:42 a.m. that day. She remembered giving the hydroxyzine. She remembered the scheduled nebulizer. She remembered checking back at 1:00 p.m. and finding the resident improved. She remembered the 4:00 p.m. albuterol treatment. She remembered the 4:45 p.m. check, the continued shortness of breath, the call to the provider, the ambulance order.
None of it was written down when it happened.
The inspection report classified the harm level as minimal harm or potential for actual harm and noted that few residents were affected. But the classification describes regulatory exposure, not the experience of a woman with a chronic lung disease who spent an afternoon struggling to breathe while the nurse caring for her left no contemporaneous record of what she observed, what she gave, or what she decided.
Resident 1 left for the emergency room. What happened after that is not in the inspection report.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 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 day shift nurse, RN #1, told inspectors she first saw the resident complain of shortness of breath and anxiety after lunch, around 12:30 p.m.
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.