Inspection Reports for BeeHive Homes of Rio Rancho II
2709 Chessman Dr NE, Rio Rancho, NM 87124 , NM, 87124
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Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 24, 2025
Visit Reason
Complaint survey completed on 07/24/2025 for state requirements of NMAC 8.370.14, Regulations for Assisted Living Facilities for Adults, triggered by complaint intake NM.
Findings
The facility failed to report incidents of exploitation within required timeframes and failed to submit follow-up reports timely. Medication misappropriation was identified involving 749 missing tablets for 4 residents, with narcotic medications not properly secured or accounted for. Resident rights violations were noted including medication substitution without physician orders and failure to provide prescribed medications. The facility's internal investigation revealed diversion of medications by House Manager #2, including removal of medication count sheets and deletion of video footage. The consulting pharmacist and facility administrator have implemented corrective actions including retraining, weekly narcotic log reviews, and quarterly audits.
Complaint Details
Complaint intake NM was investigated with deficiencies cited related to exploitation incidents and medication misappropriation.
Deficiencies (3)
| Description |
|---|
| Failed to report 4 residents' incidents of exploitation to Licensing Authority within 24 hours and submit 5-day follow-up reports timely. |
| Failed to ensure residents received prescribed medications and prevent substitution without physician orders, resulting in medication misappropriation. |
| Medication count sheets for narcotics were removed from the count book and narcotic tablets were missing, compromising accountability. |
Report Facts
Missing narcotic tablets: 749
Resident R #1 missing tablets: 141
Resident R #2 missing tablets: 268
Resident R #3 missing tablets: 200
Resident R #4 missing tablets: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| House Manager #2 | Identified as responsible for medication diversion, removal of medication count sheets, and deletion of video footage. | |
| Administrator #2 | Confirmed missing narcotic tablets and medication diversion investigation findings. | |
| Nurse #1 | Reported concerns about residents' pain management and medication availability. | |
| Direct Care Staff #5 | Reported being asked to substitute medications and observed medication administration discrepancies. | |
| Compliance Officer | Responsible for oversight of narcotic documentation and audits. | |
| House Manager #1 | Mentioned in relation to medication security and availability. | |
| Nurse Manager | Informed of medication diversion concerns and involved in investigation. | |
| Consulting Pharmacist | Responsible for quarterly medication audits and oversight of medication storage and documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jun 27, 2024
Visit Reason
The inspection was conducted as a Regulation Review and Complaint survey for the state requirements of NMAC 7.8.2, Regulations for Assisted Living Facilities for Adults.
Findings
The facility was found to have deficiencies related to improper storage of oxygen tanks, food safety violations including improper food handling and storage, and maintenance issues such as damaged window screens. One complaint was investigated and found unsubstantiated with no deficiencies cited.
Complaint Details
A complaint was investigated and found unsubstantiated with no deficiencies cited.
Deficiencies (5)
| Description |
|---|
| Failed to ensure oxygen cylinder tanks were properly secured to prevent falling and valve damage, posing a fire hazard. |
| Cooks and food handlers did not wear hair nets or caps during food preparation and serving. |
| Food stored in the refrigerator was uncovered, undated, unlabeled, and leftover food was not discarded after three days. |
| Hot food temperatures were not maintained at a minimum of 140 degrees Fahrenheit. |
| Building maintenance issues including damaged and bent window screens in multiple resident rooms. |
Report Facts
Date of survey completion: Jun 27, 2024
Number of oxygen tanks observed unsecured: 2
Food temperature: 90
Minimum required hot food temperature: 140
Timeframe for discarding leftover food: 3
Number of damaged window screens observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff #3 | Observed preparing and serving food without wearing a hair net or cap | |
| Megan Smith | Administrator | Interviewed and confirmed findings related to oxygen tanks, food handling, and window screens |
Inspection Report
Follow-Up
Census: 11
Deficiencies: 4
May 23, 2023
Visit Reason
Follow-up/Revisit survey to verify correction of previously cited deficiencies related to incident reporting, medication administration, oxygen tank storage, and window screens.
Findings
The facility failed to report incidents timely and conduct investigations for 2 residents, improperly stored unsecured oxygen tanks posing safety risks to 11 residents, and had medication administration deficiencies including unlicensed staff administering medications and incomplete MARs for 3 residents. Additionally, window screens in multiple resident rooms were bent or ill-fitting, risking resident exposure to insects or allergens.
Deficiencies (4)
| Description |
|---|
| Failure to report incidents to Licensing Authority within 24 hours and conduct investigations within 5 business days for residents #7 and #8. |
| Oxygen cylinder tanks were stored unsecured and near combustibles in residents' rooms, risking injury or fire hazard for 11 residents. |
| Medication administration errors: unlicensed staff administered medications to resident #1; medications given without physician orders; MARs lacked both brand and generic names for residents #1, #5, and #6. |
| Operable windows in multiple resident rooms had bent or ill-fitting screens, risking resident exposure to bugs or allergens. |
Report Facts
Residents with incident reporting deficiencies: 2
Residents with oxygen tank storage issues: 11
Residents with medication administration deficiencies: 3
Residents with window screen issues: 11
Incident reporting timeframe: 24
Investigation timeframe: 5
Window sill height limit: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #2 | Direct Care Staff | Observed administering medications to resident #1 without being a licensed nurse |
| House Manager | House Manager | Confirmed oxygen tank storage issues and medication administration practices; responsible for corrective actions |
| Administrator | Administrator | Confirmed findings related to incident reporting, oxygen tank storage, medication administration, and window screen deficiencies |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 11
Aug 25, 2022
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to assess compliance with state regulations for Assisted Living Facilities for Adults, including investigation of multiple complaint intakes.
Findings
The facility was found deficient in multiple areas including staff training, resident evaluations, incident reporting, medication administration records, laundry services, water temperature, emergency lighting, door safety, window screens, fire sprinkler system maintenance, and fire and safety training. Several complaints were unsubstantiated, but some deficiencies were cited.
Complaint Details
Complaint Intake NM# 58341, NM# 56963, and NM# 57891 were unsubstantiated without deficiencies cited. Complaint Intake NM# 57837 was unsubstantiated with deficiencies cited.
Deficiencies (11)
| Description |
|---|
| Direct Care Staff failed to receive sixteen hours of supervised training prior to providing unsupervised care and lacked documentation of completion. |
| Resident evaluations for 3 of 6 residents were not reviewed and revised by licensed nursing staff as required. |
| Incidents involving physical abuse and unwitnessed falls were not reported to the Licensing Authority within 24 hours and investigations were not conducted or submitted within 5 business days. |
| Medication Administration Records for 5 residents did not include both generic and brand names of medications. |
| Laundry and cleaning supplies were stored unsecured and accessible to residents. |
| Bathroom hot water temperature exceeded the maximum allowed 110 degrees Fahrenheit, measured at 118 degrees. |
| Emergency lights in the facility were not in working order at multiple locations. |
| Resident bedroom doors could not be readily opened from the inside when locked. |
| Facility windows lacked properly fitted screens, with damage observed on the living room window screen. |
| Automatic fire sprinkler system had missing or improperly installed escutcheons (plate covers) around sprinkler heads. |
| Staff and residents lacked proper fire and safety training; monthly fire drills were not conducted or documented properly, and residents did not participate in drills. |
Report Facts
Resident census: 14
Number of residents lacking required staff training: 5
Number of residents with incomplete resident evaluation review: 3
Number of residents with MAR deficiencies: 5
Hot water temperature: 118
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2013
Visit Reason
A complaint investigation was completed for intake NM00029055 on 8/22/13 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The complaint was substantiated with no deficiencies cited.
Complaint Details
The complaint was substantiated with no deficiencies cited.
Report Facts
Intake number: NM00029055
Inspection Report
Deficiencies: 0
Jan 7, 2013
Visit Reason
A survey was completed for NMAC 7.8.2 regulations governing Assisted Living facilities for intake 28529 and 28886.
Findings
No deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 21, 2010
Visit Reason
Complaint survey conducted for the requirements of NMAC 7.8.2 for Adult Residential Care Facilities related to Complaint NM27147.
Findings
No deficiencies were cited as a result of the complaint survey. The complaint was substantiated with no deficiencies. A referral was made to the State Employee Abuse Registry.
Complaint Details
Complaint NM27147 was substantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 23, 2009
Visit Reason
The inspection was conducted as a complaint investigation for New Mexico Regulations Governing Adult Residential Care Facilities 7.8.2 NMAC.
Findings
No deficiencies were cited during the complaint investigation conducted on 4/23/09-4/24/09. The complaint (NM# 27003) was unsubstantiated with no deficiencies found.
Complaint Details
One complaint was investigated (NM# 27003) and was unsubstantiated with no deficiencies cited.
Report Facts
Complaint investigation dates: 2
Inspection Report
Annual Inspection
Census: 11
Capacity: 16
Deficiencies: 6
Dec 11, 2008
Visit Reason
An annual life safety code survey was conducted to assess compliance with New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in several life safety code areas including separation of sleeping rooms from escape routes, fire alarm system inspection documentation, automatic fire sprinkler system quarterly inspection documentation, fire extinguisher inspections, staff fire safety training, fire drills, smoking area safety, and provision of self-closing metal containers for cigarette butts.
Deficiencies (6)
| Description |
|---|
| Sleeping rooms were not properly separated from escape route corridors by smoke resistant walls and doors, affecting eight resident bedrooms. |
| Fire alarm system inspection documentation was not available to verify annual inspection. |
| Quarterly fire sprinkler system inspection reports were incomplete; only one quarterly report was available and the facility was unaware of the quarterly inspection requirement. |
| Portable fire extinguishers were not inspected monthly as required; one extinguisher was last inspected on October 31, 2008. |
| Facility failed to conduct at least one fire drill each month, including drills on all shifts; no evidence of fire drills for August 2008 or graveyard shift drills between January and October 2008. |
| Smoking area was not provided with an acceptable ash tray; cigarette butts were found in a plastic coffee can. |
Report Facts
Licensed capacity: 16
Census: 11
Number of affected resident bedrooms: 8
Number of portable fire extinguishers not inspected monthly: 1
Fire drills required monthly: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Gutierrez | House Manager | Acknowledged findings and agreed to address concerns during exit conference |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 10, 2008
Visit Reason
Annual inspection to assess compliance with New Mexico regulations governing Adult Residential Care Facilities 7 NMAC 8.2.
Findings
No deficiencies were cited during the inspection. The facility is in compliance with all applicable New Mexico regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 13, 2008
Visit Reason
A complaint investigation survey was conducted on 08/13/2008 for facilities providing adult residential shelter care under New Mexico requirements 7 NMAC 8.2.
Findings
The complaint #NM26432 was substantiated but no deficiencies were cited. The facility was found to be in compliance with all New Mexico Regulations Governing Adult Residential Care Facilities 7 NMAC 8.2.
Complaint Details
Complaint #NM26432 was substantiated but no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 8
Nov 9, 2007
Visit Reason
The inspection was conducted as a complaint survey to investigate various deficiencies related to personnel records, individual service plans, medication administration, fire and safety training, and related regulatory compliance issues at Bee Hive Homes of Rio Rancho II.
Findings
The facility was found deficient in multiple areas including failure to maintain tuberculosis test results for staff, failure to review individual service plans every six months, lack of quarterly medication reviews by a consultant pharmacist, medication administration errors including missing physician orders and inaccurate transcription, failure to conduct monthly fire drills, and failure to check the Employee Abuse Registry prior to hiring.
Complaint Details
This was a complaint survey with repeat deficiencies noted from a prior complaint survey dated October 20, 2006. The findings were substantiated based on record review and interviews.
Deficiencies (8)
| Description |
|---|
| Failure to ensure all staff had tuberculosis (TB) test results on file. |
| Failure to have licensed personnel review Individual Service Plans (ISP) every six months for sampled residents. |
| Failure to ensure consultant pharmacist reviewed medication regimen at least quarterly. |
| Failure to ensure physician's orders were in resident records before continuing medication regimen for 50% of sampled residents. |
| Inaccurate transcription of prescription information into Medication Administration Record (MAR) for 50% of sampled residents. |
| Failure to conduct monthly fire drills and maintain documentation. |
| Failure to check Employee Abuse Registry (EAR) prior to employment for 2 of 4 staff. |
| Failure to ensure required training was conducted within regulatory timeframes for 1 of 4 staff. |
Report Facts
Percentage of staff without TB test results: 50
Percentage of residents without ISP review: 100
Percentage of residents with medication regimen issues: 50
Percentage of residents with inaccurate MAR transcription: 50
Number of staff without EAR check: 2
Number of staff missing required training documentation: 1
Inspection Report
Complaint Investigation
Deficiencies: 9
Oct 20, 2006
Visit Reason
A complaint investigation was conducted from 10/10/06 to 10/20/06 regarding an incident involving Resident #1 who was fatally injured during transportation by Caregiver #4. The investigation included review of policies, interviews, and record reviews related to abuse, neglect, and failure to provide required care.
Findings
The facility was found to have neglected to train and supervise caregiver staff properly, resulting in an accident causing the death of Resident #1. Deficiencies included failure to provide transportation training, failure to secure the resident properly during transport, failure to report incidents timely, and failure to maintain adequate documentation and policies related to abuse, neglect, and incident management.
Complaint Details
Complaint #NM 24369 was substantiated with deficiencies cited related to neglect and improper transportation of Resident #1 resulting in fatal injuries.
Deficiencies (9)
| Description |
|---|
| Failure to provide required care and services including exceeding licensed capacity and failure to provide an acceptable plan of correction. |
| Neglect and failure to train and supervise caregiver staff resulting in an accident causing critical injuries and death of Resident #1. |
| Failure to provide transportation training and proper supervision for employees transporting residents. |
| Failure to maintain and post Incident Management System posters and failure to follow incident reporting policies. |
| Failure to implement and maintain personnel policies including orientation, training, and documentation for employees. |
| Failure to maintain complete and accurate admission records including advance directives and resident rights documentation. |
| Failure to maintain resident records including current photographs and documentation of incidents. |
| Failure to maintain and follow medication administration policies and documentation. |
| Failure to provide safe transportation and proper training for employees assisting with resident transportation. |
Report Facts
Complaint investigation dates: 10/10/06 to 10/20/06
Resident age: 85
Mileage to accident site: 4.6
Number of residents: 11
Number of employees with deficient training: 7
Number of residents with incomplete admission records: 3
Number of residents without current photographs: 6
Number of medication administration deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #4 | Named in findings related to improper transportation and failure to seek emergency assistance | |
| Administrator | Provided multiple interviews and statements regarding training and incident details | |
| Cook/Employee #2 | First person to respond to incident, provided observations | |
| Employee #3 | Assistant Manager | Interviewed regarding training and personnel files |
| Employee #6 | Had incomplete training records and medication administration issues | |
| Manager | Interviewed regarding incident and training | |
| Deputy Field Investigator | Conducted investigation and provided findings |
Inspection Report
Routine
Deficiencies: 9
Aug 29, 2006
Visit Reason
The inspection was conducted as a routine survey of the adult residential care facility to assess compliance with state regulations including personnel policies, pet policies, emergency handling, incident reporting, medication administration, and water temperature standards.
Findings
Multiple deficiencies were identified including failure to produce TB test results for employees, lack of proof of pet vaccination, absence of emergency phone number lists, incomplete incident reporting procedures, medication administration errors, improper medication storage and labeling, and failure to maintain water temperature within required limits.
Deficiencies (9)
| Description |
|---|
| Facility failed to produce TB test results for 7 out of 7 employee files. |
| Facility failed to provide proof of vaccination for a cat residing in the facility. |
| Facility failed to have a list of emergency phone numbers near each phone. |
| Facility failed to indicate the time frame for reporting all suspected incidents to appropriate agencies. |
| Facility failed to have a thermometer in the medication-only refrigerator. |
| Facility failed to store medications in separate containers with residents' names. |
| Facility failed to label an insulin vial with resident's name as required. |
| Medication Administration Record (MAR) showed a dose not signed off by staff. |
| Facility failed to maintain water temperature between 95-110 degrees Fahrenheit; observed 115 degrees in 3 of 3 resident rooms tested. |
Report Facts
Employee TB test results missing: 7
Resident rooms tested for water temperature: 3
Medication dose not signed off: 1
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