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Complaint Investigation

Paloma Springs Healthcare Llc

August 19, 2025 · T Or C, NM · 1400 North Silver Street
Citations 1
CMS Rating 4/5
Beds 94
Provider ID 325062
Healthcare Facility
Paloma Springs Healthcare Llc
T Or C, NM  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Paloma Springs Healthcare LLC in T OR C, NM — inspection on August 19, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0842
Resident Assessment and Care Planning Deficiencies

level is considered normal for most adults) this evening, with crackles (abnormal breath sounds that

with the following feedback: Send to local emergency room via emergency medical services

quality, severity, onset, duration, aggravating factors or relieving factors of pain when they administered acetaminophen for complaints of pain on 04/12/25 at 7:08 AM, 04/12/25 at 4:19 PM, and on 04/13/25 at 4:53 PM. D. On 08/19/25 at 11:42 AM, during an interview, RN #1 stated the following:

  • She was the day shift nurse that worked with R #1 on 04/13/25. 2. On 04/13/25 after lunch (unable
  • to remember the exact time) approximately 12:30 R #1 complained of shortness of breath and anxiety.

  • RN #1 stated this was not an uncommon complaint for R #1, RN #1 further stated R #1 would have
  • increased anxiety related to diagnosis of COPD which causes her to have difficulty breathing. 4. RN #1 stated she administered hydroxyzine to R #1 at approximately 12:30 to help decrease her anxiety and help her to breathe easier. 5. RN #1 stated R #1 received her scheduled nebulizer treatment at approximately the same time (12:30 PM). 6. RN #1 stated she returned to check on R #1 after she had given her the hydroxyzine and scheduled ipratropium-albuterol (combination medication with two bronchodilators [inhaled medication that relaxes muscles in the airways which helps to open them up an make it easier to breathe]) nebulizer (approximately 1:00 PM) and resident reported the medication had helped. 7. RN #1 stated she checked on R #1 again at approximately 4:00 PM, R #1 complained of shortness of breath. RN #1 administered the PRN albuterol nebulizer treatment. 8. RN #1 stated she checked on R #1 at approximately 4:45 PM. R #1 still complained of shortness of breath and at that time also had increased weakness. RN #1 stated she contacted the on-call provider and received orders to send the resident to the emergency room via ambulance. E.

Record review of R #1's administration record (spreadsheet where nurses initial to indicate the completion of a treatment or administration of medication), dated April 2025, revealed the following: 1. RN #1 did not document that she administered PRN hydroxyzine on 04/13/25 at 12:30 PM. 2. RN #1 did not document that she administered PRN albuterol nebulizer treatment on 04/13/25 at 4:00 PM. F. On 08/19/25 at 1:24 PM, during an interview with the DON, the following was confirmed: 1. RN #1 did not document her assessments of R #1 throughout the day that prompted her to administer PRN medications. 2.

Staff are expected to document all resident assessments. 3. RN #1 did not document the administration of the PRN medications she administered on 04/13/25 4.

Staff are expected to document all medications administered on the administration record when they are given. 5.

Staff did not document the pain characteristics as indicated on R #1's care plan. 6.

Staff are expected to document at minimum the pain levels for which they are administering PRN pain medications.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in T OR C, NM, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Paloma Springs Healthcare LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.