complaint·January 14, 2026

Continued from LIC9099 When asked if the facility called 911, Complainant was told that there was no point to call 911 because R1 was fine. Per Complainant, faciity should have contacted 911 so R1 could be checked out by medical professionals since they had a history of stroke and weakness in legs was a new symptom. Review of R1's documents indicated that facility staff were to contact R1's home health agency in the event R1 experienced increased problems with balance. On 09/30/2025, 10/02/2025, and 10/07/2025, facility staff were instructed by R1's home health agency on the warning signs of stroke and who to contact if R1 experienced signs of stroke. Additional records showed that on 11/14/2025, emergency medical personnel conducted a stroke assessment for R1 where R1 denied being in pain and passed the stroke assessment. Interview conducted with Staff Member 1 (S1) stated that on 11/14/2025, R1 was observed to have unsteady gait by Staff Member 2 (S2). Due to this observation, S2 contacted S1 by phone. Interview further revealed that S1 conducted a stroke assessment over the phone with S2 who reported back their observations. Per S1, R1 was not slurring their speech, did not have drooping in their face, and did not show weakness in their arms. R1 was also not reporting any pain or dizziness, any issues with vision, and ate well during breakfast. S1 also stated that they conducted the stroke assessment two additional times on 11/14/2025 - once via video call and again during their scheduled shift at the facility. During the video call assessment, S1 noted that R1 appeared to have normal behavior apart from their unsteady gait. During the assessment conducted during their scheduled shift, S1 observed R1 to have no complaints of pain and was able to walk by themselves to the restroom without supervision. Interview conducted with Staff Member 2 (S2) stated that on 11/14/2025, they observed R1 to be "walking wobbly." Per S2, R1 denied being in pain or discomfort. Interview further corroborated statements made by S1. Per S2, they contacted S1 about R1's gait and S1 performed a stroke assessment where S2 relayed their observations verbally over the phone. S2 contacted S1 via video call so S1 could conduct a stroke assessment visually where they determined that R1 did not have any apparent signs of stroke. Interview conducted with Home Health Agency Staff stated that on 11/14/2025, they conducted a stroke assessment with R1 and did not observe any stroke symptoms apart from R1's unsteady gait. B ased on interviews conducted, record review, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.