Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paloma Springs Healthcare Llc during CMS and state inspections, most recent first.
A resident was found with unexplained injuries, including a forehead bump, facial blood, and abrasions to elbows and knees. The resident could not recall the cause of the injuries, and an LPN assessed the situation before the resident was sent to the ER and diagnosed with a contusion. The incident was not reported to the State Agency as required for injuries of unknown origin, and the administrator later acknowledged this omission.
A resident who was newly admitted to hospice care experienced a significant change in condition, but the required MDS assessment reflecting this change was not signed off by the RN within the mandated 14-day period. The delay was confirmed by both documentation and staff interview.
A quarterly MDS assessment for a resident was not completed within the required three-month timeframe, as it was finalized 14 days after the assessment reference date and lacked RN signature for completion. The MDS Coordinator confirmed the delay during an interview.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A tray of desserts in the kitchen refrigerator was found with most items missing preparation dates, contrary to facility policy requiring all prepared foods to be labeled and dated. The Dietary Director confirmed that only some desserts were dated, believing this was sufficient.
A resident was started on fluvoxamine for PTSD without documented informed consent regarding the medication's reasons, risks, and benefits. The DON confirmed that staff did not complete the required psychotropic medication consent form prior to administration, as expected by facility policy.
A resident with a history of diarrhea and gastrointestinal conditions missed multiple doses of Questran and fiber due to medication unavailability. Staff documented the missed doses and noted waiting for pharmacy delivery, but did not notify the provider about the missed medications until after several doses had been missed. The provider was only contacted later, at which point an alternative medication was ordered. Facility staff confirmed that provider notification should have occurred at the time of each missed dose, but this did not happen.
Care plan meetings were not consistently attended by all required IDT members, and meetings were not always held within the mandated timeframe after MDS assessments. In several cases, care plans were not updated to reflect new physician orders or changes in resident conditions, such as the need for daily lotion application or interventions for ongoing diarrhea. Staff interviews confirmed that providers and CNAs typically did not participate in care plan meetings or provide input, and that care plan updates were not always made as required.
A resident with gastrointestinal conditions missed multiple doses of prescribed fiber and Questran because staff did not ensure timely procurement of the medications or consistently notify the provider about missed doses. Documentation showed repeated notes of waiting for delivery, but lacked evidence of further action to obtain the medications or communicate with the provider as required by facility policy.
The facility did not ensure that physician responses to consultant pharmacist recommendations for medication regimen reviews were properly documented, including patient-specific rationales for continuing medications and communication with outside providers. Two residents with complex psychiatric and neurological conditions continued to receive medications without required documentation or follow-up, as confirmed by the DON.
A resident's room was found with orange peels, food crumbs, and paper trash on the floor, along with a lunch tray and a full urinal left on the tray table after the meal was finished. Staff confirmed these items should have been removed and the area cleaned to maintain a comfortable and homelike environment.
Two residents did not have accurate MDS assessments: one resident's dental status as edentulous was not recorded, and another resident's ongoing antipsychotic medication use was not documented in the MDS, despite clear evidence from interviews, records, and medication administration logs.
A resident with edema was prescribed furosemide, a high-risk diuretic, but the care plan did not document the diagnosis or the medication order. The DON confirmed that the care plan lacked this information, even though high-risk medications are expected to be included.
A resident with gastrointestinal conditions missed several doses of prescribed fiber and Questran medications, as documented in the MAR. Staff indicated missed doses and referenced nurse notes, but did not document provider notification in the medical record, despite contacting the on-call provider through a facility communication app. The DON confirmed the expectation for such communication to be recorded in the resident's medical record, resulting in incomplete and inaccurate documentation.
An Activity Aide in an LTC facility exploited a resident's financial resources by using their debit card for unauthorized personal purchases, totaling nearly $3,000. The aide was identified through security footage and subsequently arrested and terminated. The facility had already revised its shopping process to prevent future incidents before the survey investigation.
A facility failed to create an accurate baseline care plan within 48 hours of admission for a resident identified as a high fall risk. Despite a fall risk evaluation indicating the resident's high risk, the baseline care plan did not include this information. The ADON confirmed the omission during an interview.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) for one resident. According to the incident report, the resident was found in bed with blood on her face, bed, floor, and in the trashcan. The resident was unable to recall what had happened or whether she had fallen. Nursing staff assessed the resident, noted a bump on her forehead, blood on her face, and abrasions to both elbows and knees, but could not determine the source of the bleeding. The provider was notified, and the resident was sent to the emergency room for further evaluation, where she was diagnosed with a contusion. Despite the unclear circumstances and the resident's inability to explain the injury, the incident was not reported to the SA as required for injuries of unknown origin. The interdisciplinary team later discussed the incident and concluded that the resident had likely fallen, but the administrator acknowledged that the incident should have been reported to the SA. The failure to report the incident meant that the SA was not able to review or investigate the potential neglect.
Failure to Timely Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required 14-day timeframe after a major change in a resident's condition. Specifically, a resident was admitted to hospice care as ordered by the physician, indicating a significant change in health status. However, the significant change MDS assessment was not signed off by the RN until several weeks later, exceeding the 14-day requirement. This was confirmed by both record review and interview with the MDS coordinator, who acknowledged the assessment was not completed within the mandated period.
Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment was completed every three months for one of four residents reviewed for MDS assessments. Specifically, for one resident, the quarterly MDS assessment had an assessment reference date (ARD) of 11/14/25 but was not signed by the RN for completion and was completed 14 days after the ARD. During an interview, the MDS Coordinator confirmed that the assessment was not completed on time. This resulted in the resident's assessment being outdated at the time of review.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Label and Date Prepared Desserts in Kitchen Refrigerator
Penalty
Summary
The facility failed to store food under sanitary conditions for all 81 residents who consumed food from the kitchen. During an observation of the kitchen's walk-in refrigerator, a tray containing 12 desserts was found, with eight of the desserts lacking a date to indicate when they were prepared. In an interview, the Dietary Director confirmed that eight out of the 12 desserts on the tray did not have dates on their lids and stated that having a few with dates on the same tray should suffice. A review of the facility's Food Labeling and Dating policy, revised on 01/25/25, revealed that all food items prepared for a meal are required to be labeled and dated.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed in advance about the administration of a psychotropic medication, specifically fluvoxamine, including the reasons for its use, as well as its risks and benefits. Record review showed that the resident had a physician's order for fluvoxamine to be given twice daily for post-traumatic stress disorder (PTSD), but there was no documentation of consent for this medication in the medical record. During an interview, the DON confirmed that staff did not obtain the required psychotropic medication consent form prior to starting the medication, despite facility expectations that this form be completed before administration.
Failure to Notify Provider of Missed Medication Doses for Resident with Diarrhea
Penalty
Summary
The facility failed to notify the provider when a resident missed multiple doses of prescribed medications intended to manage diarrhea and promote colon health. The resident, who had a history of diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of digestive tract parts, was admitted with orders for Questran and fiber tablets. Over a period in March and April, the resident missed at least 8 doses of Questran and 12 doses of fiber, as documented in the medication administration record (MAR). Progress notes repeatedly indicated that the medications were not available and that staff were waiting for pharmacy delivery, with nurses being made aware of the situation. However, there was no documentation that the provider was notified about the missed doses of either Questran or fiber during this time. The only provider notification occurred after several missed doses, when staff contacted the on-call provider, who then ordered an alternative medication (Imodium A-D). Interviews with staff confirmed that the standard process required notifying the provider and documenting the communication whenever a resident missed any medication doses. The Director of Nursing verified that, prior to the eventual notification, staff had not contacted the provider regarding the missed doses of Questran or fiber, and that such notification should have occurred at the time of each missed dose.
Deficient Care Plan Development, IDT Participation, and Timely Revisions
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted with the required interdisciplinary team (IDT) members for several residents. In multiple instances, care plan meetings were held with only select staff present, such as the Social Services Director, RN, or Activity Director, while other required contributors like the MDS Coordinator, Nurse Aide, Food Service Staff, and Physician were marked as not applicable or did not participate. Interviews with staff confirmed that providers and CNAs typically do not attend or provide input for care plan meetings, and that input from all required disciplines was not routinely sought. Additionally, the facility did not consistently hold care plan meetings within the required 7-day timeframe following the completion of the Minimum Data Set (MDS) assessments. For some residents, there was no documentation of a care plan meeting occurring within seven days after the MDS was completed, and in one case, the care plan meeting was held before the MDS assessment was finalized. Staff interviews confirmed these timing discrepancies and the lack of adherence to required scheduling protocols. The care plans were also not revised to reflect the most current resident information and physician orders. For example, one resident had a new order for daily application of lotion to the extremities, but this intervention was not added to the care plan. Another resident with a history of diarrhea and multiple related physician orders did not have these diagnoses or interventions reflected in the care plan. The DON confirmed that these updates should have been made to ensure the care plans were accurate and current.
Failure to Administer Medications as Ordered Due to Inadequate Medication Procurement and Notification
Penalty
Summary
The facility failed to meet professional standards of quality by not administering medications as ordered by the physician for one resident. The resident, who had diagnoses including diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of parts of the digestive tract, had physician orders for fiber tablets and Questran to manage their gastrointestinal conditions. Despite these orders, the medication administration records showed multiple instances where both fiber and Questran were not administered as prescribed over several weeks. Documentation in the medication administration record and progress notes indicated that staff repeatedly noted the medications were not available and were waiting for delivery from the pharmacy or local store. However, there was no documentation that staff took further steps to obtain the medications in a timely manner, such as contacting the pharmacy, notifying the staff member responsible for purchasing over-the-counter medications, or escalating the issue to ensure the resident received the ordered therapy. Additionally, staff did not consistently notify the provider about the missed doses, as required by facility policy, with only one documented instance of provider notification after several missed doses had already occurred. Interviews with nursing staff and the DON confirmed that the expected procedures for medication shortages were not followed. Staff were expected to notify the provider and document communication for each missed dose, as well as to contact the pharmacy or arrange for over-the-counter medication purchases. The facility's own policy required these actions, but records and interviews showed that these steps were not consistently taken, resulting in the resident missing multiple doses of prescribed medications.
Failure to Document Physician Response to Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations regarding medication regimen reviews were properly reviewed and implemented by the physician, or that the physician provided documentation with a patient-specific rationale for not following the recommendations. For two residents, the pharmacist had recommended gradual dose reductions (GDR) for medications including Doxepin, Prazosin, and Bupropion for one resident, and hydroxyzine and haloperidol for another. In these cases, the physician either did not provide a rationale for continuing the medications or failed to document that the recommendations were sent to outside providers for review. One resident had multiple psychiatric and sleep-related diagnoses and was receiving several medications for these conditions. The pharmacy made repeated recommendations for GDR, but the physician did not provide patient-specific reasons for continuing the medications, and there was no documentation that recommendations were communicated to the outside provider responsible for some of the prescriptions. The Director of Nursing (DON) confirmed that no rationale or follow-up was documented for these recommendations. Another resident with severe dementia, anxiety, and auditory hallucinations was prescribed hydroxyzine and PRN haloperidol. The pharmacy recommended a GDR for hydroxyzine and discontinuation or documentation for continued PRN use of haloperidol. The physician's responses were incomplete, lacking patient-specific rationale and anticipated duration of use for the PRN medication, and the haloperidol order did not have an end date. The DON confirmed the absence of required documentation in the medical record.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
Staff failed to maintain a safe, clean, and homelike environment for one resident, as evidenced by the presence of orange peels, food crumbs, and paper trash on the floor of the resident's room. Additionally, a lunch tray from an earlier meal remained on the resident's tray table well after the meal was finished, and a full urinal was left on the same tray table. These conditions were confirmed by both a CNA and the facility Administrator during interviews, who acknowledged that the room should have been cleaned, the tray removed after the meal, and the urinal emptied and taken off the tray table. The observations and interviews directly document the failure to provide a comfortable and homelike environment as required, with specific details about the uncleanliness and improper handling of personal care items in the resident's room.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, interviews and record reviews revealed that she was edentulous and required dentures, but her Admission MDS did not reflect her lack of natural teeth. The MDS Coordinator was unaware of the resident's dental status at the time of assessment and confirmed that the information was not accurately entered. For another resident, physician's orders and medication administration records showed that the resident was receiving daily haloperidol, an antipsychotic medication, over several months. However, the Quarterly MDS inaccurately documented that the resident had not received any antipsychotic medications. The MDS Coordinator confirmed the resident was receiving haloperidol and acknowledged the omission on the MDS assessment.
Failure to Include High-Risk Medication and Diagnosis in Care Plan
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for one resident with a diagnosis of edema. Record review showed that the resident was admitted with edema and had a physician's order for furosemide, a high-risk diuretic medication, to be administered daily. The resident's Minimum Data Set Assessment also indicated the use of a high-risk diuretic. However, the care plan, as revised, did not document the resident's diagnosis of edema or the order for furosemide. During an interview, the Director of Nursing confirmed that the care plan did not include the resident's use of furosemide, despite facility expectations that high-risk medications be included in care plans.
Incomplete Documentation of Missed Medication Doses and Provider Notification
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident with multiple gastrointestinal diagnoses, including diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of digestive tract parts. Record review showed that the resident had physician orders for fiber tablets and Questran to manage their conditions, but the medication administration record (MAR) documented multiple missed doses of both medications over March and April. Staff used codes indicating missed doses and referenced progress or nurse notes, but there was no documentation in the medical record that the provider was notified about the missed doses. During an interview, the DON confirmed that the resident missed several doses of Questran and fiber, and that staff had contacted the on-call provider through a facility communication application regarding the unavailability of Questran. However, this communication was not documented in the resident's medical record, contrary to facility expectations. The lack of documentation regarding provider notification and missed medication doses resulted in incomplete and inaccurate medical records for the resident.
Unauthorized Use of Resident's Debit Card by Activity Aide
Penalty
Summary
The facility failed to prevent staff exploitation of a resident's financial resources, leading to unauthorized use of a resident's debit card by an Activity Aide (AA). The incident involved the misuse of a resident's bank debit card by AA #1, who made unauthorized withdrawals and purchases totaling nearly $3,000. The resident's Power of Attorney (POA) discovered the missing funds and reported suspicious charges, prompting a police investigation. The investigation revealed that AA #1 used the resident's debit card for personal expenses, including gas, groceries, baby clothes, and alcohol. The facility's records showed that AA #1 had been destroying documents and receipts, further complicating the situation. The police used security footage to identify AA #1 as the individual responsible for the unauthorized transactions, leading to her arrest and termination from the facility. The deficiency was identified as past noncompliance, as the facility had already implemented corrective measures before the survey investigation. These measures included revising the shopping process to ensure only the Activity Director could handle residents' financial transactions, and conducting audits to verify the return of cards, change, and receipts to residents.
Failure to Develop Accurate Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for one of the two residents reviewed. The record review revealed that the resident was admitted to the facility on an unspecified date, and a fall risk evaluation conducted on April 26, 2024, indicated that the resident was at high risk for falls. However, the baseline care plan, dated April 29, 2024, did not include this critical information about the resident's high fall risk. During an interview on July 23, 2024, the Assistant Director of Nursing confirmed that the baseline care plan did not reflect the resident's high fall risk, which is a necessary component for ensuring appropriate care immediately upon admission.
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What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near T Or C
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Mexico State Veterans Home | 1.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.