On 11/19/2025, LPA interviewed Staff (S1), who stated that R1’s daughter submitted a 60-day written notice for R1 to vacate the apartment; however, according to S1, R1 did not fully vacate the building. S1 stated that the facility does not have possession of the security or pet deposits because those funds were managed by a former management group.

LPA reviewed the Resident Service Agreement (Admission Agreement) signed and dated by R1 on 09/10/2022, which lists a move-in date of 09/11/2022. LPA reviewed R1’s Resident Billing Information, which listed a security deposit of $500.00 and a pet deposit of $500.00, totaling $1,000.00.

LPA also reviewed the Community Fee provision, which states that the Community Fee is not a security deposit and may only be refundable under certain conditions. The agreement states that if a resident terminates the agreement during the third month of residency, the resident may be entitled to 40% of the balance after a $500 deduction. The agreement further states that after the third month of residency, no portion of the Community Fee is refundable. Documentation reviewed indicated that the Community Fee was waived at the time of admission. Staff (S1) further stated that, according to information provided by the previous management group, the $500 security deposit and $500 pet deposit are forfeited 90 days after the admission date. Based on record review, R1 moved over 90 days after the admission date. Therefore, pre-admission fees are forfeited.

Based on the information obtained, there is insufficient evidence to support the allegation that staff did not provide a refund to the resident. Therefore, the allegation is Unfounded.

W1 reported that upon arrival, R1’s bedroom door was locked, and facility staff did not have a key readily available to unlock the door. Once the door was opened, W1 stated that R1 was found wedged between the bed and the nightstand and unable to get up.

LPA reviewed the facility call log, which indicates that on 03/17/2025 R1 activated the call pendant alert system two times. The first activation occurred at 3:14:48 PM with a response time of 26.87 minutes, which was answered by staff. The second activation occurred at 5:08:38 PM, documented as a non-emergency accidental press, and was answered within 0.47 minutes.

On 03/07/2026 LPA interviewed, S2, S3, S4, S5 and S6 and all collaborated that residents may activate the call button for extended periods before staff are able to respond due to insufficient staffing and workload demands.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that staff did not respond to Resident (R1)’s call button is substantiated.

LIC9099-C Continued...

Allegation: Staff did not ensure resident received medical care as needed

On 03/07/2026 LPA interviewed S2, S3, S4, S5 and S6 all stated if any resident has sustained an injury such as a cut that a medication technician or nurse can administer first aid such a bandage. S2, S3, S4, S5 and S6 do not recall the incident occurring on 03/17/25 with R1. LPA reviewed Accident/Incident Report (dated 03/17/25) indicating that R1 sustained an injury with a cut on left arm and that an ointment was applied to arm. LPA reviewed “Observations for R1” (dated 03/01/25 – 11/19/25) that notes an observation by staff indicating R1 had an unwitnessed fall in their room. Cut was observed on left arm and that staff clean the cut an applied an antibiotic ointment.

Based on interviews conducted, the preponderance of evidence standard has been met; therefore, the allegation that staff did not ensure Resident (R1) received medical care as needed is substantiated.

LIC9099-C Continued...