Vineyard Park of Bremerton.

Conclusion / Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A . Investigation Summary Report Provider/Facility: Vineyard Park of Bremerton Provider Type: Assisted Living Facility License/Cert.#: 2695 Intake ID: 151696 Compliance Determination #: 46959 Region/Unit#: RCS Region 3 J Unit D Investigator: Shelley Neeleman Investigation Date(s): 09/10/2024 through 11/12/2024 Complainant Contact Date(s): Allegation(s): Other - Admission, Discharge, Transfer Rights: 1) The AV2 was playing Bingo when the facility boxed up his belongings, got him out of Bingo and took him to his daughters with no notice. 2) The AV2 did not have his medications at his daughter's house and had to go back to get his medications from the facility. Investigation Methods: Sample: Total residents: 1 Resident sample size: 1 Closed records sample size: Observations: General environment Residents Resident rooms Staff Staffing levels Resident to staff interactions Interviews: Staff Collateral Contacts AV2 Record Reviews: Resident Characteristic Roster Face Sheet Notice of Prehearing Conference, request date 09.20.2024 Service Plan Progress Notes CPMG Resident services Policies and Procedures: Resident Discharge, annual review 09.01.2024 Boarding Home Transfer and Discharge Notice, dated 07/15/2024 Boarding Home Transfer and Discharge Notice, dated 09/01/2024 AV2's Resident Rental and Admission Agreement, dated 06/19/2024 Email from AL TSA Social Services Specialist 5 to the AV2's . daughter, dated 06/26/2024 at 11 :35 a.m. Email from DSHS Public Benefits Specialist 4/Home and Community Services to Social Services Specialist 5, Biz Office VP, Executive Director, AV2's daughter, dated 07/22/2024 at 4:35 p.m. Email from Executive Director to Ombudsman, dated 09/19/2024 at 1:09 p.m. Email from Executive Director to Ombudsman, dated 10/03/2024 Email from Executive Director, dated 10/31/2024 at 5:05 p.m. Email from Executive Director, dated 10/31/2024 at 5:19 p.m. Email from Executive Director, dated 11/05/2024 at 3:48 p.m. Email from Care Partners CEO, dated 11/05/2024 at 4:04 p.m. Email from Care Partners CEO, dated 11/06/2024 at 9:52 a.m. Email from Executive Director with attached statement of the timeline of events from Business Office Manager, dated 10/31/2024 at 3:42 p.m. Statement from Maintenance Director, dated 11/05/2024 Investigation Summary: 1) Per interview and record review, the AV2 was driven by facility staff to the daughter's home on /2024 with three boxes of clothing and some medications, and was unaware of a discharge date. Record review of "Boarding Home Transfer and Discharge Notice", dated 09/01/2024, documented "date notice is given" was 07/16/2024, the date notice was "mailed out" was 07/16/2024, the original notice was sent out on 07/15/2024, and the discharge "effective date" was 09/25/2024. The "discharge address" indicated on the notice was a Willow Street address, which was not the actual discharge location. The form did not indicate where the notice was sent or if the notice was received. A record review did not identify written notification of an 2024 discharge date to the AV2. The facility failed to notify the resident of the discharge in writing and in a language and manner understood by the resident, and failed to provide the effective date of discharge, as outlined in WAC 388.78A.2660(1) and RCW 74.129.110(3)(b)(5)(b). A Statement of Deficiency outlining the failed practice is being submitted for the related intake #149385. 2) Per interview and record review, the AV2 received some medications at the time of discharge, but not the as-needed narcotic medications, which the AV2 was taking regularly for chronic pain. The AV2 and daughter had to retrieve the narcotic medications from the facility the following morning. The facility failed to provide sufficient preparation and orientation to ensure a safe and orderly discharge from the facility, as outlined in WAC 388.78A.2660(1) and RCW 74.129.110(6). A Statement of Deficiency outlining the failed practice is being submitted for the related intake #149385. . Conclusion / Action: ~ Failed Provider Practice Identified/ Citation(s) Written D Failed Provider Practice Not Identified / No Citation Written □ N/A 11/21/2024 . ST ATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 2695 Compliance Determination # 46959 Plan of Correction Vineyard Park of Bremerton Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 09/10/2024 and 11/12/2024 of: Vineyard Park of Bremerton 2707 Clare Ave Bremerton, WA 98310 This document references the following complaint number(s): 142634, 149385, 151696 The following sample was selected for review during the unannounced on-site visit: 1 of 1 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Shelley Neeleman, ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. 757 ~ R tIa are Se rvI.c es Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . 11.21.2024 15:23:04 State of Washington Statement of DefiGiencies .License#: 2695 Compliance Determination# 46959 Plan of Correction Vineyard Park of Bremerton Completion Date Administrator (or Representative) Date WAC 388-78A-2660 Resident rights. The assisted living facility must: (1) Comply with chapter 70.129 RCW, Long-term care resident rights; This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure ·1 of 1 sampled resident (Resident 1 [R1]) had a safe and orderly discharge from the facility. This failure resulted in R1 being discharged from the facility without sufficient preparation to ensure R1's safety and put R1 at risk for a decreased quality of life. Findings included ... "RCW 70.129.110(3)(b)(5)(b)(6) Disclosure, transfer, and discharge requirements ... (3) Before a long-term care facility transfers or discharges a resident, the facility must. .. ; (b) Notify the resident and resident representative of the transfer or discharge and the reasons for the move in writihg and in a language and manner they understand ... ; (5) The written notice specified in subsection (3) of this section must inch:.1de the foilowing ... ; (b) The-effective date of transfer or discharge; (6) A facility 111u:;l JJI t.iviut:t :;uffit;it111l Pl t:lfJi::lf.:llio11 tHlU uiit:JI 1lc:1livr I lu 11::l~iut:Jr 1l~ lV t:Jrll:iUlt:J ::$i::lrt:J i;U 11.i Urt.it:ir fy lr c:lll~ft:Jr ur discharge from the facility; (7) A resident discharged in violation of this section has tile right to be readmitted immediately upon the first availability of a gender-appropriate bed in the facility." Record review of the facllity's policy titled, "CPMG Resident Services Policies and Procedures - Resident Discharge'', annual review on 09/01/2024, showed that "If necessary and allowed by applicable law, the facility will, with proper written notification, ensure· an efficient, safe, and organized transfer .... (2) CarePartners Senior Living will attempt through reasonable accommodations to avoid transfer or discharge. If the transfer or discharge is unavoidable then the faqility will: (a) notify the resident and his qr her representative and make reasonable efforts to notify, if known, any interested family members of the resident and the reasons for the move in writing and in a language and manner that they can understand ... : (c) include in the notice ... : ii) the effective date of transfer/discharge ... ; (4) Care Partners Senior Living will provide sufficient pr!:lparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility ... ; (6) A resident dischatged in violation of this section has the right to be readmitted immediately or as soon as the first gender-appropriate bed or apartment in the facility becomes avallable." Record review of R 1 's Face Sheet, no date provided, showed that R 1 moved into the facility on /2024. . Statement of Deficiencies License #: 2695 Compliance Determination # 46959 Plan of Correction Vineyard Park of Bremerton Completion Date Administrator (or Representative) Date WAC 388-78A-2660 Resident rights. The assisted living facility must: (1) Comply with chapter 70.129 RCW, Long-term care resident rights; This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 1 sampled resident (Resident 1 [R1]) had a safe and orderly discharge from the facility.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 2695 Compliance Determination # 50937 Plan of Correction Vineyard Park of Bremerton Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 11/25/2024 and 11/25/2024 of: Vineyard Park of Bremerton 2707 Clare Ave Bremerton, WA 98310 This document references the following complaint number(s): 156295 The following sample was selected for review during the unannounced on-site visit: 5 of 94 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Nikolas Jennings, Community Nurse Complaint Investigator Jody Just, Field Services Administrator From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . Statement of Deficiencies License #: 2695 Compliance Determination # 50937 Plan of Correction Vineyard Park of Bremerton Completion Date Administrator (or Representative) Date WAC 388-78A-2730 Licensee's responsibilities. (1) The assisted living facility licensee is responsible for: (a) The operation of the assisted living facility; (b) Complying at all times with the requirements of this chapter, chapter 18.20 RCW, and other applicable laws and rules; and (c) The care and services provided to the assisted living facility residents. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to comply with the requirements of chapter 18.20 Revised Code of Washington (RCW), when the Licensee interfered with 3 of 3 Long-Term Care (LTC) Ombuds’ (Collateral Contacts 1, 2, & 4[CC1, 2, & 4]) ability to complete their responsibilities and duties as a resident advocate. This failure resulted in the ombuds being accused of abuse, ombuds feeling intimidated, and impacted the ability of the ombuds to effectively advocate for all 94 residents. This placed all residents at risk for infringement of their rights and a decreased quality of life. Findings included… RCW 18.20.180, Resident Rights, stated: RCW 70.129.050 through 70.179.170 apply to this chapter and persons regulated under this chapter. RCW 70.129.090 Advocacy, Access, and Visitation rights, subsection 1(c) stated: The resident has the right and the facility must not interfere with access to any resident by the following: The state long-term care ombuds as established under chapter 43.190 RCW. Washington Administrative Code 365-18-120, Interference with the Ombudsman’s Liability, stated: (1) It is unlawful under 42 U.S.C. Sec. 3058g(j) and RCW 43.190.090 to take any discriminatory, disciplinary, or retaliatory action against the following persons: (a) Any employee of a facility or agency; (b) Any resident or client of a long-term care facility or family member of a resident; (c) Any ombudsman; or (d) Any person; for any communication made, or information given or disclosed, to an ombudsman . Statement of Deficiencies License #: 2695 Compliance Determination # 50937 Plan of Correction Vineyard Park of Bremerton Completion Date carrying out his or her duties unless that person acted maliciously or without good faith. (2) It is unlawful to willfully interfere with ombudsmen in the performance of their official duties. Record review of the Department’s Complaint Investigation working papers, dated 11/05/2024 at 1:24 PM, showed that Collateral Contact 8 (CC8), the Department Investigator, notified Staff A, the Facility’s Administrator, that the facility would be receiving a citation related to the discharge of Resident 1 (R1). The Complaint Investigation working papers showed that R1 was receiving advocacy support from CC2, a LTC ombuds, to appeal the discharge. Record review of an email dated 11/06/2024, showed Staff B, the facility’s Management Company’s CEO, sent an email to the following people: Staff A (Facility Administrator), The Department, CC2 (LTC Ombuds), and the Facility’s Management Company’s attorney. This email was sent one day after the facility was informed that they would be receiving a citation and included CC2, the LTC ombuds, on the email. The email was inviting The Department to attend a meeting discussing current Resident 2’s pending discharge from the facility. In the email, Staff B stated, “The fact is a certain party is coaching our residents, and their families, that they do not have to pay their residency invoices and they can stay in our community without any consequences. All you have to do is object to place of discharge as ‘unsafe.’ Or claim falsely you didn’t receive the notice. This in my mind is elder abuse because it promotes unlawful actions and it creates false hope and expectations. This sort of action isn’t ‘advocacy but illegal activism.’ To me as a mandatory reporter, I will call anything like this – even if suspected – to APS and have them investigate. This is elder abuse at its highest.” In an Interview with CC1, a LTC ombuds, on 11/21/2024 at 10:23AM, CC1 stated that Staff B “has a right to complain but the way that he does to me is intimidating to my team members and has caused them stress. CC2 is tough, and even she is distressed by this.” CC1 stated that a complaint was filed (to the department) because they feel that Staff B will continue to retaliate against ombuds advocacy. CC1 stated, “I speculate that this is all about the corporation not liking the fact that there is an advocate who is presenting all options to a resident who is being involuntarily discharged.” In an interview with CC2 on 11/21/2024 at 2:02PM, CC2 stated that there has been a lack of respect for resident rights ever since the facility was obtained by the Facility’s Management Company. CC2 stated, “I feel like my legs were cut off, getting an email from Staff B insinuating that I have questionable ethics and that I am misleading residents and giving them false hope. There was a pit in my stomach, why should I be upset and aggravated walking into the building to just do my job. It became an aggressive defensive situation, but having to bring the assistant state ombuds on the phone with me, it just infuriated me.” CC2 stated that they expect things to get worse following these emails but isn’t going to stop doing their job. In an interview with CC4, LTC ombuds, on 11/27/2024 at 1:47PM, CC4 stated, “I walk lightly when I go in there especially when I talk to the administration. They will tell me one thing, then do the opposite. If they don’t like what I am doing, they will file a . Statement of Deficiencies License #: 2695 Compliance Determination # 50937 Plan of Correction Vineyard Park of Bremerton Completion Date complaint against me.” In an interview with Staff B on 12/03/2024 at 4:00PM, Staff B was asked about the email dated 11/06/2024 referenced above, that was sent to Staff A, The Department, and CC2 (LTC ombuds). Staff B stated that they did not email CC2. Staff B stated that in Staff B’s judgement, the residents are being coached to lie by CC2. Staff B stated “I have never had an activist like that. This is a person who will proudly say that everything she is doing is advocating for the residents. What she is actually doing is being an activist.” In an interview with Staff A on 12/04/2024 at 2:53PM, Staff A stated that after receiving notification from The Department on 11/05/2024 that the facility would be receiving a citation, Staff A notified Staff B. Staff A, when asked if they thought that the communication they had with Staff B regarding the citation was what led to the emails Staff B sent on 11/06/2024, stated “yes.” Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Vineyard Park of Bremerton is or will be in compliance with this law and / or regulation on (Date)________________ .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 November 21, 2024 ELECTRONIC-FACSIMILE Administrator Vineyard Park of Bremerton 2707 Clare Ave Bremerton, WA 98310 Assisted Living Facility License # 2695 Licensee: Laurel Glen ALC LLC IMPOSITION OF CIVIL FINE Dear Administrator: On November 12, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Vineyard Park of Bremerton, located at 2707 Clare Ave, Bremerton, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated November 12, 2024. Civil Fine WAC 388-78A-2660 (1) Resident rights. $400.00 The licensee failed to ensure one resident had a safe and orderly discharge from the facility. This failure resulted in the resident being discharged from the facility without sufficient preparation to ensure the resident’s safety and put them at risk for a decreased quality of life. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Vineyard Park of Bremerton License # 2695 November 21, 2024 Page 2 Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected. • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Vineyard Park of Bremerton License # 2695 November 21, 2024 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $400.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Vineyard Park of Bremerton License # 2695 November 21, 2024 Page 4 If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, For: Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3 Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . [jJ □ □ . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTR.ATION Staternei1t of Deficiencies License #: 2695 Compliance Determiliatlon # 41764 Plan of Correction Vineyard Pane of Brernerton Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 05/23/2024 and 05/23/2024 of: Vineyard Park of Bremerton 2707 Clare Ave Bremerton, WA 98310 This document references the following complaint number(s): 130054 The following sample was selected for review during the unannounced on-site visit: 0 of 0 current residents and O former residents. The department staff that investigated the Assisted Living Facility; Michael Goulet, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residentfal Care Services, Region 3 , Unit D Lakewood, WA 98496 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. 06/03/2024 ······--·---•·•··--·· ~~t~Services···--······-··. .......... . Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . Statement of Deficiencies License#: 2695 Compliance Determination# 41764 Plan of Correction Vineyard Park of Bremerton Completion Date W11/UZ.I/ Administrator (or Representative) Date WAC 388~78A-2040 Other requirements. (1) The assisted living facility must comply With all other applicable federal, state, county and municipal statL1tes, rule$, codes and ordinances, including without limitations those that prohibit discrimination. This requirement was not met as evidenced by: Based on observatlon, interview and record review, the assisted Jiving facility failed to meet the requirements of the state Fire Marshal, and failed to rectify violations noted by the Fire Marshal during the Fire Marshal inspections of the facility on 12-19-23, 2-6-24 and 5-8-24, Failure to address these violation placed all 84 residents and staff at risk of Physical harm. Findings Included ... Record review on 5-13-24 at 8:35am of the Fire Marshal Report of inspection of the facility showed that the facility remained out of compliance following the third Fire Marshal inspection regarding linen storage being closer than three feet to an electrical panel, and regarding not providing documentation of inspections for the faoil!ty fire sprinkler system, the kitchen fire suppression system and the facility's carbon monoxide detectors. Observation on 5-23-24 at 10:40am of the facility linen closet in question did show that the facility had taped off the floor of the closet in front of the electrical panel in this room, in order to communicate to staff that linen carts and other objects ,could not be placed so as to block access to the electrical panel, but that linen storage shelving was still within three feet of the electrical panel. No linens or clothing were observed in the closet, and there was access to the electrical panel at the time of observation, but it was unclear if the shelving unit being within three feet of the electrical panel would violate the Fire Marshal requirements as stated in the Fire Marshal Inspection Report. During an interview on 5-23-24 at 10:10am, the facility executive director (Staff A) stated that all of the issues named in the final Fire Mar.shat Inspection Report had been addressed prior to the Fire Marshal leaving the facility on 5-8-24, and that all of the inspection docL1ments related to the facility sprinkler system, the kitchen fire suppression sys ten, ar1d tl1e facility carbor monoxide detectors had been available at that time, but as of this writing none of these documents had been provided by the facility. Plan/Attestation Statement . Statement of Deti~iencles license#: 2695 Compliance Determination #41764 Plan of Correction Vineyard Park of Bremerton Completion Date I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Vineyard Park of Bremerton is or will be in compliance with this law and/ or regulation on (Date)-1:/ltJ/tRPI . In addition, I will implement a system to monitor and ensure continued compliahce with this requirement ~ ~ E. t> ....... ...l.t/1..7/i !?.P.:!. ............................. . Administrator (or Representative) Date . Plan of Correction Agency Name Citation Date Vineyard Park of Bremerton 5/31/24 Submitted by Date of POC Submission Lisa Carlock 7/3/24 D Complaint Citation D Certification Citation Citation: (list WAC) WAC 388-78A-2040 Describe the initial or immediate actions taken. Since acquiring Vineyard Other Requirements Park of Bremerton, we have changed our fire monitoring and testing company to PSI. All required testing had been done at the time of the fire marshal's visit but we did not have documents on-site due to an error on PSl's onboarding. We made every effort possible to get the records of testing onsite, calling daily, leaving messages, emails etc. Unfortunately, they were not here when Fire Marshal returned. We now have the documentation here in our fire book. The Sprinkler System, Kitchen fire suppression system and carbon monoxide detectors were all tested, and all passed at the time service was due. There was no risk to residents as the tests were completed on time. How will you apply the System or Operational Changes: I had a meeting with one of the owners of correction to all clients you PSI and our local rep regarding the lack of follow through with returning support? reports and testing. They assured me it will be handled differently and apologized profusely. I made it clear how important it is that we have these documents on hand within 7 days of work being done and they assured me it will happen. We also set up an on line portal with them so we can access it at anytime. This had not been set up yet at this location since this building was new to their system Who will be responsible to Ann Kershul- Regional Maintenance Director implement change and monitor Keith Starke- Maintenance Manger the corrections to ensure the Lisa Carlock- Executive Director problems do not reoccur? Date by which lasting correction We are live on our portal now and have all testing documents on site .. will be achieved 7/1/2024 Additional Information I do believe this is something that I would IDR but have decided not to spend time on that process, rather move forward knowing that we did do our testing as required and our residents and staff were always safe. The concern with linen closet having items in it, as Michael said in his report, the area is taped off, there is nothing in the taped off area. This will also continue to be monitored. Submit to RCS within 10 calendar days of receipt of letter to: