complaint·December 18, 2025

(Continued from LIC9099, Page 1) Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported no knowledge of other staff members who were rough or caused injuries to residents. Staff denied forcing residents to go to bed early. When asked about forcing residents to bed, S3 stated that it was counterproductive for the facility to force residents to bed as it increases a resident's likelihood to practice exit-seeking behaviors. S3 stated, "residents are happier when we provide choices and freedoms for them." Interviews with Residents corroborated staff interviews that caregivers do not tell residents to go to bed early or that they physically force residents to go to bed against their will. With reference to injuries from showering, in an interview with R1, they stated that even though they know they are not supposed to shower without help due to a history of falls, they attempted to shower by themselves before they were found by care staff and assisted. Records review confirmed that R1 has a history of Dementia, Major Depressive Disorder, and Anxiety Disorder. The care notes for R1 stated on 10/17/2022, (10 days prior to the initiated complaint), R1 "demanded to go to bed at 3pm." When staff came back to check on R1 an hour later, they found R1 on the floor. Staff did a safety check to ensure there were no injuries and helped them back into their bed. Additionally, R1's care plan corroborated that R1 required assistance with showering. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.