complaint·February 3, 2026

Regarding: Staff changed resident’s care plan without resident’s consent. It is alleged that staff changed resident’s care plan without resident’s consent. Staff deny the allegation. Interviews with Staff 1 – Staff 4 (S1-S4) revealed that staff have not changed resident’s (R1) Care Plan without their consent. Staff indicated that staff have not made changes to R1’s Care Plan. Staff indicated that in order to make changes to a resident’s Care Plan, a re-evaluation from the wellness staff must be conducted before determining if changes to residents’ Care Plan need to be made to best meet their needs. Interview with S1-S3 indicated that R1 has not been re-evaluated to determine if a change to their Care Plan is warranted. S1-S3 further indicated that R1’s Care Plan continues to stand since R1 was last assessed by staff on 10/21/2025. Interview with S5-S9 indicated that they are not part of the team who determines if changes need to be made to residents’ Care Plans and were unable to provide information regarding the allegation. Interview with R1 indicated that staff are trying to make changes to R1’s Care Plan without R1’s consent. However, file review conducted by LPA revealed that R1’s Care Plan is still current and there have been no changes since 10/21/2025. Interviews with R2 – R12 indicated that their needs are being met by facility staff and have no concerns regarding their Care Plan being changed without their consent. Based on interviews and record review, the allegation that staff changed resident’s Care Plan without resident’s consent could not be corroborated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.