Inspection Reports for BeeHive Homes of Clovis
2305 N Norris St, Clovis, NM 88101 , NM, 2305 N Norris St, Clovis, NM 88101
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Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 11
May 20, 2022
Visit Reason
The inspection was conducted as an onsite and complaint survey related to state requirements for assisted living facilities, including substantiated complaint intake NM#53865.
Findings
The facility was found deficient in multiple areas including staff qualifications and training, resident activities, incident reporting, nutrition and food safety, laundry services, lighting, fire drills, hospice care, and memory care unit requirements. Deficiencies included failure to complete required background checks and training prior to hire, lack of posted activity calendar, failure to report incidents timely, expired and improperly stored food, unsecured hazardous chemicals, non-functional emergency lighting, lack of fire drills, incomplete hospice and dementia training, and inadequate documentation and care coordination.
Complaint Details
Complaint Intake NM#53865 was substantiated with deficiencies cited related to staff qualifications and training.
Deficiencies (11)
| Description |
|---|
| Direct Care Staff did not receive Employee Abuse Registry clearance prior to hire. |
| Direct Care Staff failed to complete required 16 hours supervised training and 12 hours orientation prior to providing unsupervised care. |
| Resident activities calendar was not posted for residents, families, and visitors. |
| Incidents of possible abuse, neglect, or exploitation were not reported to Licensing Authority within required 24 hours. |
| Food stored in refrigerators and freezers was expired, unlabeled, uncovered, and leftovers were kept longer than 3 days. |
| Poisonous and flammable chemicals were stored unsecured and accessible to residents in the laundry room. |
| Emergency lights in the facility were not in working order. |
| Fire drills were not conducted monthly on each 8-hour shift as required. |
| Residents and/or guardians did not receive fire safety and evacuation orientation upon admission. |
| Direct Care Staff failed to complete required 6 hours of hospice/palliative care training annually including 1 hour specific to hospice resident's ISP. |
| Direct Care Staff failed to complete required 12 hours of Alzheimer's/Dementia training annually. |
Report Facts
Residents on census: 9
Expired food items: 8
Chemicals unsecured: 11
Fire drills missing: 4
Direct Care Staff missing training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darlene Marshall | Administrator | Confirmed deficiencies and provided corrective action plans during interviews. |
| Direct Care Staff #1 | Employee file reviewed showing late Employee Abuse Registry clearance and missing required trainings. | |
| Direct Care Staff #2 | Employee file reviewed showing missing required trainings. | |
| Direct Care Staff #3 | Employee file reviewed showing missing required trainings. |
Inspection Report
Routine
Deficiencies: 0
Jul 29, 2020
Visit Reason
An offsite surveillance was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance.
Inspection Report
Routine
Deficiencies: 0
Apr 20, 2020
Visit Reason
An offsite surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were identified during the Covid 19 infection prevention and control survey.
Inspection Report
Routine
Deficiencies: 0
Mar 19, 2020
Visit Reason
An onsite surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the Covid 19 infection prevention and control survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 15, 2016
Visit Reason
A Revisit survey was conducted on 11/15/16 following an Initial survey dated 07/18/15 and a prior Revisit survey dated 04/14/16 to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited as a result of the 11/15/16 survey and the facility was found to be in compliance.
Inspection Report
Re-Inspection
Deficiencies: 6
Apr 14, 2016
Visit Reason
Revisit survey for an Initial survey dated 07/18/15 to assess compliance with state requirements for Assisted Living facilities.
Findings
The facility had new and repeat deficiencies related to admissions, resident evaluations, medication storage, nutrition, hospice care, and memory care unit compliance. Deficiencies included failure to hold required team meetings prior to admitting hospice residents, incomplete resident evaluations, improper oxygen storage, uncovered kitchen garbage, and lack of physician orders for memory care placement.
Deficiencies (6)
| Description |
|---|
| Failed to ensure Admission/Retention Exception team meeting was held prior to admitting 1 resident receiving hospice services. |
| Failed to complete initial resident evaluations within 15 days prior to admission and to review evaluations every 6 months. |
| Failed to ensure oxygen cylinder tanks were stored securely, not with combustible materials, and lacked 'Oxygen in Use' signs for 4 residents. |
| Kitchen garbage can was uncovered and did not have a tight fitting lid. |
| Failed to hold Admission/Retention Exception team meeting prior to admitting 1 hospice resident. |
| Failed to obtain physician orders stating the need for placement in a memory care (secured) unit for 4 residents. |
Report Facts
Days late for Admission/Retention team meeting: 43
Residents reviewed for evaluations: 5
Residents with missing physician orders for memory care placement: 4
Residents receiving hospice services: 4
Residents with oxygen storage issues: 4
Residents in memory care unit reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed deficiencies related to Admission/Retention team meetings, oxygen storage, and physician orders for memory care placement. | |
| House Manager | Confirmed deficiencies related to Admission/Retention team meetings, resident evaluations, oxygen storage, and physician orders for memory care placement. |
Inspection Report
Original Licensing
Census: 5
Deficiencies: 13
Jul 8, 2015
Visit Reason
Initial licensure survey conducted to assess compliance with New Mexico requirements for Assisted Living for Adults.
Findings
The facility was found deficient in multiple areas including staff qualifications, staff training, policies, medication administration, resident records, fire drills, and other regulatory requirements. Deficiencies were documented with corrective actions planned.
Deficiencies (13)
| Description |
|---|
| Failure to provide training and information to staff and residents on reporting incidents or suspected abuse, neglect, and exploitation. |
| Failure to provide required training related to Dementia, Alzheimer's disease, palliative/hospice care, and supervised training prior to providing care. |
| Failure to implement written personnel policies including staff qualifications, medication administration, and resident records. |
| Failure to maintain complete and accurate resident records including admission agreements, evaluations, service plans, and documentation of abuse reporting. |
| Failure to conduct monthly fire drills on each shift and maintain accurate fire drill records. |
| Failure to maintain sanitary food service practices and proper food storage temperatures. |
| Failure to provide staff training on fire and safety procedures and ensure staff preparedness for emergencies. |
| Failure to provide training for employees assisting with hospice services and ensure coordination of care. |
| Failure to post activities calendar and provide appropriate recreational and social activities for residents. |
| Failure to maintain medication administration records and provide required medication training to staff. |
| Failure to complete resident evaluations and individual service plans within required timeframes. |
| Failure to maintain resident rights documentation and provide information on reporting abuse and neglect. |
| Failure to maintain water temperature within required range and ensure sanitary conditions. |
Report Facts
Resident census: 5
Training hours: 16
Training hours: 12
Training hours: 6
Training hours: 1
Fire drill frequency: 1
Fire drill duration: 8
Hot water temperature range: 95
Hot water temperature range: 110
Medication administration training hours: 6
Resident evaluation timeframe: 15
Resident evaluation update timeframe: 6
Individual Service Plan (ISP) timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| House Manager | Confirmed employees were not receiving required training and monitored ongoing compliance. | |
| Administrator | Provided resident census list and stated assumptions about staff training. | |
| Caregiver CG #1 | Observed preparing food without hairnet during inspection. | |
| Caregiver CG #3 | Personnel file reviewed for training documentation. |
Inspection Report
Life Safety
Capacity: 15
Deficiencies: 0
Apr 21, 2015
Visit Reason
An initial life safety code survey was conducted at the facility per the provider's request.
Findings
The facility was found to be in substantial compliance with the Life Safety Code portion of the New Mexico State Regulations for Assisted Living Facilities for Adults 7.8.2 NMAC. Temporary licensure for a maximum capacity of 15 residents is recommended.
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