Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 17, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to compliance with state requirements for assisted living facilities, specifically regarding nutrition and food handling practices.
Findings
The facility was found deficient for failing to ensure that cooks and food handlers wore hair nets or caps at all times during food preparation, which could pose a risk of foodborne illness to residents. Other aspects of nutrition and food safety policies and procedures were detailed but no other deficiencies were cited.
Complaint Details
The complaint survey was completed on 10/17/2025. Complaint Intake NM # was investigated with no deficiencies cited for those specific complaints. The cited deficiency relates to food handler protective garments.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure cooks and food handlers wore hair nets or caps at all times when engaged in handling food, drink, utensils, and equipment. |
Report Facts
Dates for corrective actions: Hairnets purchased on 10/16/25; in-service training scheduled by 11/13/25.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook #5 | Observed and confirmed to have prepared lunch without wearing a hairnet or cap. | |
| Operations Manager | Confirmed that Cook #5 prepared lunch without a hairnet or cap and provided census information. |
Inspection Report
Follow-Up
Census: 14
Deficiencies: 1
May 31, 2023
Visit Reason
The visit was an offsite Revisit/Follow-up survey to assess compliance with state requirements for Assisted Living for Adults, specifically reviewing previously cited deficiencies.
Findings
The facility failed to ensure that resident evaluations were completed within 15 days prior to admission for 1 of 2 residents reviewed, which is an uncorrected deficiency from a prior survey dated 10/27/22.
Deficiencies (1)
| Description |
|---|
| Failure to complete resident evaluation within 15 days prior to admission for 1 of 2 residents reviewed. |
Report Facts
Resident Census: 14
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed that resident evaluation was not completed within 15 days prior to admission |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 10
Oct 27, 2022
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to investigate multiple complaint intakes (IDs #NM 00049972, #NM 00059942, #NM 00061420) related to the state requirements of 7.8.2. NMAC Regulations for Assisted Living Facilities for Adults.
Findings
The facility was found to have multiple deficiencies including failure to ensure staff qualifications and timely clearance checks, incomplete resident evaluations and individual service plans, lack of posted emergency contact numbers, failure to report incidents timely, improper storage of oxygen tanks, food safety violations including expired and improperly stored food, unsecured laundry and cleaning supplies, and housekeeping issues such as unlocked chemical storage and unclean kitchen areas.
Complaint Details
The visit was complaint-related with three complaint intake IDs investigated: #NM 00049972 (unsubstantiated, no deficiencies), #NM 00059942 (unsubstantiated with deficiencies cited), and #NM 00061420 (unsubstantiated with deficiencies cited).
Deficiencies (10)
| Description |
|---|
| Failure to ensure direct care staff received Employee Abuse Registry (EAR) clearances and Caregiver Criminal History Screening Program (CCHSP) fingerprint applications within required timeframes. |
| Failure to complete resident evaluations within 15 days prior to admission and to review/update evaluations every 6 months. |
| Failure to develop and implement Individual Service Plans (ISPs) within 10 days of admission and to review/revise ISPs every 6 months. |
| Failure to post an activities calendar for residents, families, and visitors. |
| Failure to post emergency contact phone numbers near public telephones including fire, police, ambulance, and poison control. |
| Failure to report incidents to Licensing Authority within 24 hours and conduct investigations within 5 business days. |
| Oxygen cylinder tanks were stored unsecured, near combustible materials, and within 15 feet of ignition sources, violating NFPA 99 standards. |
| Kitchen equipment and work areas were not clean and in good repair; expired and unlabeled food was stored in refrigerators; food leftovers were kept longer than 3 days. |
| Laundry and cleaning supplies were stored unsecured in unlocked laundry room accessible to residents. |
| Poisonous or flammable substances were stored in unlocked kitchen areas accessible to residents. |
Report Facts
Residents on census: 10
Deficiency count: 10
Fine amount: 5000
Days for evaluation completion: 15
Days for ISP completion: 10
Temperature range: 35
Temperature range: 41
Temperature: 0
Temperature: 140
Distance: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operations Manager | Operations Manager | Named in multiple interviews confirming findings and corrective actions. |
| Assistant Manager | Assistant Manager | Named in corrective action plans and monitoring compliance. |
| House Manager | House Manager | Confirmed findings related to expired food and kitchen conditions. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 4, 2020
Visit Reason
The inspection was conducted as an Offsite Complaint survey related to Complaint #NM45361, which was substantiated with one deficiency cited regarding incident reporting and resident rights.
Findings
The facility failed to report an incident involving a resident's injury of unknown origin to the Licensing Authority within the required 24 hours and did not conduct an internal investigation or submit a follow-up report within 5 business days. Additionally, the facility failed to ensure that residents were treated with courtesy, respect, dignity, and compassion, and free from physical and emotional abuse by staff, as evidenced by video footage showing inappropriate staff behavior toward a resident.
Complaint Details
Complaint #NM45361 was substantiated. The complaint involved failure to report and investigate an incident involving Resident #1 and abuse/neglect of Resident #2 by Direct Care Staff #4, who was terminated after video evidence confirmed the abuse.
Deficiencies (2)
| Description |
|---|
| Failure to report incidents of unusual occurrence with injury to the Licensing Authority within 24 hours and failure to conduct timely internal investigations and follow-up reports. |
| Failure to ensure residents are treated with courtesy, respect, dignity, and compassion and free from physical and emotional abuse by Direct Care Staff. |
Report Facts
Residents reviewed for compliance: 5
Deficiencies cited: 2
Incident reporting timeframe: 24
Investigation timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| House Manager | Reported failure to report incident and confirmed abuse incident after video review. | |
| Administrator | Participated in exit interview confirming incident reporting failures and abuse incident. | |
| Direct Care Staff #4 | Involved in abuse of Resident #2, terminated after video evidence confirmed misconduct. |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 15
Sep 17, 2015
Visit Reason
Full-Onsite survey with one complaint NM00029769 for the New Mexico Requirements for Assisted Living for Adults, 7.8.2 NMAC.
Findings
The facility was cited for multiple deficiencies including lack of staff training documentation, incomplete policies, inadequate medication management, poor food safety practices, incomplete resident records and ISPs, lack of fire drills and safety training, improper hazardous area protections, and insufficient hospice training for staff.
Complaint Details
Complaint NM00029769 was substantiated with no deficiencies.
Deficiencies (15)
| Description |
|---|
| Failed to have documentation of 16 hours of supervised training prior to providing unsupervised care and 12 hours of annual training for caregivers. |
| Failed to have and implement written personnel policies including staff qualifications, training, criminal history screening, emergency procedures, medication administration, and personnel records maintenance. |
| Failed to ensure admission agreements included notification of residents' rights and bed hold policy. |
| Resident records were incomplete, not organized with a table of contents, missing bed hold policy, dentist info, MAR, and signed notes. |
| Failed to maintain required facility reports, records, rules, policies and procedures including fire drills, emergency plans, staff training, and medication destruction documentation. |
| Failed to ensure Individual Service Plans (ISP) were complete, accurate, signed, dated, and filed in resident records. |
| Failed to post an activities calendar or program to meet residents' psychosocial needs. |
| Failed to protect resident rights by not providing written information about services and not ensuring resident participation in care plan development. |
| Failed to ensure proper medication and oxygen storage, and proper destruction of discontinued medications. |
| Failed to obtain signed consent for medication assistance and maintain accurate, complete Medication Administration Records (MARs). |
| Failed to ensure planned, nutritionally balanced meals, safe food handling, proper food storage, posting of menus, and maintenance of temperature logs. |
| Failed to keep soiled linen separate from clean linen, store linens in a clean ventilated area, and secure hazardous chemicals. |
| Failed to ensure laundry room door self-closing device was functioning, posing fire hazard. |
| Failed to conduct monthly fire drills on all shifts and provide fire and safety training to staff and residents. |
| Failed to provide required hospice training for staff assisting hospice residents. |
Report Facts
Resident census: 12
Hours of staff training required: 16
Hours of annual staff training required: 12
Hours of hospice training required: 6
Hours of hospice training specific to resident ISP: 1
Last fire drill date: Jun 20, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| House Manager | Named in relation to lack of staff training documentation and interview confirming missing training | |
| Assistant Manager | Named in relation to lack of staff training documentation and interview confirming missing training | |
| Caregiver #1 | Named in relation to lack of staff training documentation | |
| Caregiver #2 | Named in relation to lack of staff training documentation and medication administration issues | |
| Caregiver #3 | Named in relation to lack of staff training documentation, food safety violations, and fire drill interview |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 24, 2014
Visit Reason
The inspection was conducted to assess compliance with New Mexico requirements for Assisted Living for Adults under 7.8.2 NMAC.
Findings
No deficiencies were cited during the survey, indicating full compliance with the applicable regulations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 14, 2014
Visit Reason
A complaint investigation was completed for intake NM #29584 on 11/14/14 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living. The complaint was substantiated with a deficiency cited.
Findings
The facility failed to identify that one resident had a vancomycin resistant enterococcus (VRE) urinary tract infection, which requires contact isolation. This knowledge deficit prevented the facility from implementing contact precautions to protect other residents. The facility also lacked policies for isolation procedures for residents with resistant infections.
Complaint Details
The complaint was substantiated. The investigation found that the resident with VRE UTI was admitted without proper identification of the infection, and the facility did not have isolation procedures in place. Interviews revealed that treatments were unknown to the administrator and that staff did not coordinate medication records properly.
Deficiencies (1)
| Description |
|---|
| Facility failed to identify a resident with VRE urinary tract infection and implement required contact isolation precautions. |
Report Facts
Date of resident admission: Oct 11, 2013
Date of positive urine culture: Dec 29, 2013
Date of infection treatment order: May 21, 2014
Date of interview with doctor: Nov 12, 2014
Date of interview with administrator: Nov 12, 2014
Date of interview with staff D#2: Nov 12, 2014
Date of interview with facility manager: Nov 13, 2014
Date of interview with administrator: Nov 13, 2014
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 24, 2014
Visit Reason
A complaint investigation was conducted for intake NM00029505 on 09/24/14 regarding the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The complaint was found to be unsubstantiated with no deficiencies cited as a result of the complaint; however, deficiencies were cited as a result of discovery related to hazardous areas and fire safety requirements.
Complaint Details
The complaint was unsubstantiated with no deficiencies cited as a result of the complaint.
Deficiencies (1)
| Description |
|---|
| Facility failed to have a self closing device on the 1 and 3/4 inch solid bonded wood core door to a hazardous area equipped with a self closer device for fire suppression in the laundry room, which is a hazardous area. |
Report Facts
Date of complaint intake: Sep 24, 2014
Number of residents affected: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
May 22, 2014
Visit Reason
The inspection was conducted as a complaint investigation for Assisted Living for Adults under New Mexico Requirements, related to Complaint # NM 29377.
Findings
No deficiencies were cited during the complaint investigation survey. The complaint was substantiated and a referral was made to the New Mexico Department of Health Employee Abuse Registry.
Complaint Details
Complaint # NM 29377 was substantiated. A referral was made to the New Mexico Department of Health Employee Abuse Registry.
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 6, 2011
Visit Reason
An initial survey was completed on 1/6/2011 to assess compliance with regulatory standards at Bee Hive Homes of Santa Fe.
Findings
No deficient practices were cited as a result of this survey.
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