complaint·September 22, 2022

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to commence a complaint investigation and deliver findings. LPA identified herself to Administrator Maritza Lujan who was notified of the reason for today’s visit. LPA discussed the purpose of the visit and the elements of the allegation. The investigation included staff and resident interviews, inspection of the resident rooms, and records review. The allegation is that Facility utilizes bed rails without medical order. Records reviewed show that some residents utilize bed assist rails. Interview with Resident 1 (R1) revealed that they use a single side rails to transfer in and out of bed. R1 stated that the facility removes the rails however R1 puts the rails back on to avoid falls when transferring to and from their bed. LPA observed resident rooms and found bed assist half rails. Based on the available information, we have found the complaint allegation is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegations occurred. An exit interview was conducted where this report was discussed and a copy provided to Administrator Lujan.