Oakwood Healthcare Center

F-F609.

2. ADM did not report an unusual occurrence of a facility lockdown.

3. ADM did not ensure the building equipment was operating and the environment was safe. Refer to

F-F908.

This put all residents at risk for ongoing abuse and accidents and hazards.

Findings:

During a review of the facility undated document titled, Administrator Job Description, indicated the administrator (ADM) reports to Governing Body & President of Operation. The ADM's principal responsibilities and duties are serves as liaison between Governing Body and Facility Personnel, implementing performance improvement initiatives to ensure that residents are continuously improving. Directing and monitoring compliance with federal and state regulations and laws. Coordinating compliance with established policies and procedures. Allocating resources to effectively carry out facility programs. Recruiting, hiring, and training competent and committed staff. Fostering cooperative rapport with and between departments fostering the importance of each staff member's contributions to the facility. Positioning the facility to operate in a successful manner.

During a review of facility P&P titled AN07 Abuse-Reporting and Investigations, dated 1/3/24, the P&P indicated the purpose: To protect the health, safety, and welfare of facility residents. The facility will (a) report all allegations of abuse and criminal activity as required by law and regulations to appropriate agencies and (b) will promptly report and thoroughly investigate allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled using technology, misuse/stealing of resident property, injuries of unknown source, and any suspicion of crimes.

During concurrent observation of facility bulletin board at the Unit 2 nurses' station and review of posted facility P&P titled Abuse - Prevention, Screening, & Training Program dated 7/2018, the P&P indicated the facility does not condone any form of resident abuse and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse and mistreatment. The P&P indicated the Administer as abuse prevention coordinator is responsible for implementation (putting into effect) of the facility's abuse prevention, screening, and training program policies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 055656 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 1. a. During a review of record titled Resident Grievance/Complaint Investigation Report, dated 5/30/24 [sic],

the record indicated Resident 1, in a handwritten statement, reported an older man from laundry dept. came Level of Harm - Minimal harm or into her room, began putting clothes away, he started chit-chatting [sic] with me and getting closer . Before I potential for actual harm knew it, he was up against my bed then he began . (handwriting stopped there). Immediate Corrective Action Taken: Room female only. No males allowed in room. Investigation Initiated: 5/31/24. Assigned Department's Residents Affected - Some Response to Grievance: Laundry supervisor notified of complaint. Staff educated and in-serviced on going into female-/male-only rooms. Was the grievance confirmed? No. Resident will be monitored for psychosocial wellbeing, and room will be kept female only until needed. Follow-up Required? No.

During review of record titled Interdisciplinary Team (IDT) Note, dated 6/19/24 at 4:37 pm, the record indicated team members present were SSD, Nursing Supervisor (NS), Director of Nursing (DON), Activities Director (AD), and Administrator (ADM). The record indicated Resident 1 was at risk for decline in psychosocial well-being due to an incident on 5/30/24 of feeling uncomfortable when a male staff member touched her shoulder. The record indicated a facility consultant and SSD deemed it appropriate to open an Adult Protective Services (APS) case, and a report was filed 6/19/24.

During a review of Facility-Reported Incident Intake Information received at State Agency California Department of Public Health, dated 6/20/24 at 7:56 am, the report indicated alleged physical , and psychological/mental employee-to-resident abuse occurred on 5/30/24 when a male from the laundry came into Resident 1's room and touched her shoulder, which made her uncomfortable. The record indicated the alleged abuse resulted in no physical injury.

During an interview with Resident 1 on 7/10/24 at 1:40 pm, Resident 1 stated she remembered the incident with LP2 but could not remember the words LP2 said to her. Resident 1 stated she was drowsy and nodding off in her bed, eyes closed. Resident 1 stated it sounded like someone was putting away clothes in the closet and she came to to find LP2 caressing her left shoulder and whispering in her ear. Resident 1 stated she froze because his actions made her very uncomfortable. Resident 1 stated she spoke to SSD and a grievance was filed on 5/31/24.

During an interview with SSD on 7/18/24 at 3 pm, SSD stated a corporate consultant was reviewing facility grievances and stated Resident 1's grievance dated 5/31/24 should have been reported to state. SSD stated

she didn't recognize it as abuse at the time but now thinks it could be considered that. SSD stated the consultant verbally reeducated her with abuse training and could not provide a record of that. SSD stated Licensed Vocational Nurse 2 (LVN2) was the first to hear report of LP2-to-Resident 1 abuse. SSD stated, We [staff] are all mandated reporters. SSD stated the facility protocol is, Usually the first person to hear about the abuse reports it. However, SSD stated she does most of the reporting because she is often the first to hear about abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 055656 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During concurrent interview with ADM on 7/18/24 at 2:15 pm and review of records titled [LP2] 4/15/2024 - 7/18/2024 (timecards showing days/hours worked), ADM stated, Within 24 to 48 hours of starting the Level of Harm - Minimal harm or investigation, we identified it was [LP2] as the perpetrator of abuse to Resident 1 on 5/30/24. During review potential for actual harm of timecard time stamps, ADM acknowledged LP2 had been suspended with pay for three days while the abuse allegation was investigated (6/20, 6/21, and 6/22/24 - 20 days after the incident). The record indicated Residents Affected - Some LP2 returned to work five more days (6/26 - 6/29/24 and 7/2/24) before his termination effective 7/3/24. When asked if LP2's behavior toward Resident 1 had been unacceptable, ADM stated LP2 did a gesture that's done 5000 times a day by CNAs to residents. ADM stated Resident 1's room had been made female only while they investigated without knowing LP2's identity because of Resident 1's being uncomfortable with

the incident. ADM stated their investigation of the incident revealed LP2 was determined to not be a threat. ADM stated SSD interviewed other residents, and they let him come back.

1.b. During a review of Facility-Reported Incident Intake Information received by State Agency, dated 6/21/24 at 7 am, the record indicated alleged resident-to-resident abuse occurred when Resident 2 asked Resident 3

a series of sexually oriented questions. The record indicated Resident 3 suffered sexual and psychological/mental abuse resulting in mental suffering.

During a review of Resident 3's Alert Note, dated 6/20/24 at 10:27 pm, indicated Resident 3 stated she still has feelings of distress related to the incident of being harassed and inappropriate sexual behavior by another resident.

During a review of record titled Smoking Residents, interviews conducted 6/27/24, the record indicated Resident 3 reported feeling safer. Resident 5 reported she was scared Resident 2 would come back to the facility at night, noting that Resident 2 is mad at her and others. Resident 5 stated she is afraid the doors will be left unattended and Resident 2 will come in. Resident 15 reported feeling uncertain of knowing what Resident 2 is capable of doing, concerned he could possibly be carrying a weapon. Resident 6 reported seeing Resident 2 behind a facility fence and was afraid of him hopping over the fence. Resident 6 reported feeling uneasy, anxious, and stated Resident 2 should be arrested. Resident 14 reported feeling ok but stated she did witness Resident 2 being aggressive to others and him needs to stay away. Resident 12 reported anxiety, afraid Resident 2 may come back with a weapon. Resident 12 reported seeing Resident 2 behind the facility, feeling unsafe that he keeps showing up at the facility.

During an interview with Director of Nursing (DON) on 7/3/24 at 3:45 pm, DON stated we did our best with Resident 2 while he was at the facility. DON stated Resident 2 put inappropriate notes on his door, and facility residents complained that they were intimidated or frightened by the notes. DON stated Resident 2 once informed her he had been in prison for [AGE] years for murder; DON believed it was to let her know he was someone she should take seriously. DON stated Resident 2 had been homeless prior to admission. DON stated Resident 2 would have erratic behavior and often had strange visitors, noting his behavior would get worse after the visitors left. DON acknowledged concern for potential substance use while he was in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 055656 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an interview with OMB on 7/5/24 at 8:48 am, OMB stated she was familiar with Resident 2 and noted, while she was not a medical professional, she was sure he had a major mental illness. OMB stated his Level of Harm - Minimal harm or thought process was tangential (adding irrelevant or excessive details to conversation) and he willfully tried potential for actual harm to aggravate other residents by saying very crude things to them. OMB stated he was discharged against medical advice but was coming back trying to agitate people, at one point throwing bottles toward the Residents Affected - Some building. OMB stated ADM reported Resident 2 had returned to the facility twice since discharge and police had been called. OMB stated he had not hit a resident with a bottle to her knowledge. OMB stated, I'm assuming [Resident 2] will get 5150'd (an involuntary 72-hour psychiatric hospitalization for adults in danger of harming themselves or others) at one point. OMB stated the facility attempted to get a 5150 for Resident 2, but police told ADM ' Cussing and words' didn't qualify as 5150. OMB stated Resident 2 was awful, noting

he was going into a young woman's room saying very inappropriate things like, ' Suck my d*ck.' OMB stated staff did a lot of work because they were concerned with his safety and others'.

2. During a review of facility Policy and Procedure (P&P) titled Unusual Occurrence Reporting, dated 8/1/12,

the P&P indicated its purpose was to ensure timely reports are made to designated agencies as required by state and federal laws and regulations. The P&P further indicated the facility will report by phone and in writing to the appropriate State or Federal agencies allegations of abuse or neglect and other unusual occurrences that interfere with facility operations and affect the welfare, safety, and health of residents, employees, or visitors. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate.

The Administrator (ADM) did not report placing the facility on lockdown (all doors and windows were locked, staff and residents remained inside) while local law enforcement searched the area for a former resident (Resident 2) who threw bottles at the building.

During an interview with ADM on 7/18/24 at 2:15 pm, ADM stated Resident 2 had returned to the facility after his discharge, and police had been notified. ADM stated he had called the police twice, and the facility was placed in lockdown (all doors and windows locked, staff and residents inside) at one point while law enforcement searched for Resident 2. ADM acknowledged that the lockdown should have been reported to State Agency but was not. ADM initially stated Resident 2 had not been inside the facility since his discharge but later stated, I take that back. He made it in once. ADM stated Resident 2 returned to visit a resident. ADM stated, I escorted him to the room with the receptionist, resident didn't want to see him, and we walked him out. Asked if he was aware staff and residents were reporting concern that Resident 2 kept returning, ADM stated, I have had no note of that from staff. ADM stated SSD interviewed all the residents who smoke for four weeks, and they stopped the interviews because their answers indicated all was well. ADM offered to provide copies of two police reports at a later time: one from the lockdown and one from an incident where drugs were removed by law enforcement from the property (source unknown). Police reports had not been received as of 7/24/24.

3. During a review of facility records titled Administrator (ADM) Job Description, undated, the record indicated ADM is responsible for directing and monitoring compliance with federal and state regulations and laws, coordinating compliance with established policies and procedures, hiring and training competent and committed staff, and positioning the facility to operate in a successful manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 055656 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Resident 5 lived in her bedroom for three days with an unreported ceiling leak from a malfunctioning rooftop air conditioning unit. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/10/24 at 4:41 pm with ADM and SSD, ADM stated, [MS] didn't tell me it had gotten that bad. I looked at it this morning, and it was not dripping like that. Residents Affected - Some

During an interview with MS on 7/18/24 at 10:59 am, MS stated he did not have invoices describing findings of damage and/or repairs performed by plumbing and HVAC companies from the week of 7/8/24. MS stated

he requested copies from the vendors and would send them to State Agency via email. Invoices had not been received as of 7/24/24.

During an interview with Activities Personnel 2 (ACT2) on 7/18/24 at 12:58 pm, ACT2 stated Resident 5 was upset about the leak in her room.

During an interview with ADM on 7/18/24 at 2:15 pm, ADM stated the facility determined the leak was a result of the air conditioning pipes having a lot of condensation (water collects on a cold surface in the presence of humid air). ADM stated the pipes got plugged by debris from landscaping maintenance. ADM stated, The condensation mixes with the debris and makes mud and water can't pass through.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 055656 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49418 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain essential equipment in safe Residents Affected - Some operating condition when:

1. An air conditioning unit leaked for three days from the ceiling in room [ROOM NUMBER]A (Resident 5's bedroom). This failure resulted in Resident 5 stating she felt frustrated and worried and had the potential for avoidable life-threatening hazards such as ceiling collapse from water damage, electrocution, and infection from mold and bacterial growth.

2. Facility staff silenced a malfunctioning fire system alarm for five hours. Failure to maintain the fire system had the potential to place all 89 residents, staff, and visitors at risk of injury or death in the event of a fire.

Findings:

During a review of facility Policy and Procedure (P&P) titled Maintenance Service: Operational Manual - Physical Environment, dated 1/1/12, the P&P indicated its purpose was to protect the health and safety of residents, visitors, and staff by maintaining all areas of the buildings, grounds, and equipment in a safe and operable manner at all times. The Maintenance Department is responsible for maintaining fire alarm system, heating and cooling system, plumbing fixtures, wiring, etcetera, in good working order. The Director of Maintenance is responsible for maintaining records/reports of building inspections, work order requests, and maintenance schedules. Maintenance staff follow established safety regulations to ensure the safety and well-being of all concerned.

1. During a review of facility record titled Maintenance Log, dated 4/30/24 to 7/18/24, the record indicated on 7/8/24, specific Issue/Problem: Ceiling leaking from curtain track in room [ROOM NUMBER]A.Date Addressed: 7/9/24.Target date: Vendor called to find location of leak. Date Completed: 7/9/24.

During an interview with Resident 5 on 7/10/24 at 1:45 pm, Resident 5 stated, It's raining in my room. Resident 5 stated she informed staff Sunday, 7/7/24, that water was dripping from the ceiling near her television. Resident 5 stated staff put a big bucket under the leak. Resident 5 stated she was worried her television would get ruined and did not have the money to replace it. Resident 5, who was in a wheelchair, stated she was frustrated because she had difficulty getting around the bucket to the bathroom and on one occasion almost urinated in her chair.

During observation of room [ROOM NUMBER] on 7/10/24 at 3:04 pm, observed a steady drip of clear liquid from a metal curtain track in the ceiling. The liquid dripped into a 50-gallon garbage can that had been placed below the leak. The room had two beds; the garbage can was located beside the foot of Bed A (Resident 5's bed) between the bed and the doorway. Bed A was nearest the entryway; Bed B was on the far side of the room near the windows and bathroom. Bed B was not occupied.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 055656 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During a concurrent observation and interview with Maintenance Supervisor (MS) on 7/10/24 at 3:07 pm, MS stated he had received a call late Sunday night (7/7/24) about a possible leak in room [ROOM NUMBER]. Level of Harm - Minimal harm or MS stated he called a local heating, ventilation, and air conditioning (HVAC) company on 7/8/24. MS stated a potential for actual harm local plumber inspected the leak on 7/9/24 who indicated the issue was not plumbing-related. MS stated he returned a call to the HVAC company and made an appointment for 7/11/24 to stop condensation leaking Residents Affected - Some from air conditioning pipes. MS showed me his mobile work phone indicating (1) an open work order for the leak in room [ROOM NUMBER]A and (2) photos revealing moist areas in the attic above room [ROOM NUMBER].

During a review of facility record titled Open Work Order #324, created 7/8/24 at 2:45 pm by Social Services Director (SSD), the record indicated Room/Area: room [ROOM NUMBER]A.Notes: Plumber inspected on 7/9/24 said it's not a plumbing issue or a fire sprinkler issue but an HVAC issue. [HVAC company name] was called. Scheduled to be out 7/11/24. Location: In room. Priority: Medium.

During an interview with Administrator (ADM) on 7/10/24 at 4:33 pm, ADM stated he was aware room [ROOM NUMBER] had a leak since 7/7/24. ADM stated MS informed him the leak was scheduled for repair tomorrow (7/11/24) at 11 am with a plan to let Resident 5 stay in the room.

During concurrent observation of room [ROOM NUMBER] and interview with Resident 5 on 7/10/24 at 4:35 pm, observed Resident 5 sitting in her wheelchair in the hallway, looking into her room while speaking with unknown staff member about the leak. Observation of room [ROOM NUMBER] revealed a wet towel in the doorway and a large puddle on the floor surrounding the garbage can. Resident 5 stated the leak was getting worse and housekeeping had been called to mop the floor. Resident 5 stated she did not want to move to another room but would be okay moving to the other (unoccupied) side of her room. ADM, SSD, and Director of Staff Development (DSD) arrived at the room at approximately 4:37 pm. DSD stated to Resident 5 that

she must move to another room for safety reasons until the leak was fixed.

During an interview on 7/10/24 at 4:40 pm with ADM and SSD, ADM stated he had observed the leak in room [ROOM NUMBER]A on the morning of 7/10/24, and it was not dripping like that. ADM stated MS had not informed him the leak had gotten that bad.

During an interview with MS on 7/18/24 at 10:59 am, MS stated he did not have invoices describing findings of damage and/or repairs from plumbing and HVAC companies from 7/9/24 and 7/11/24, respectively. MS stated he had requested copies from the vendors and would send them to State Agency via email. Invoices have not been received.

During an interview with ADM on 7/18/24 at 2:15 pm, ADM stated the facility determined the leak was a result of the air conditioning pipes having a lot of condensation (water collects on a cold surface in the presence of humid air). ADM stated the pipes get plugged by debris from landscaping maintenance. ADM stated, The condensation mixes with the debris and makes mud and water can't pass through.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 055656 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 2. During a review of [Vendor Name] Service Request by Repair Person 1 (RP1), dated 7/9/24 at 1:21 pm,

the record indicated Scope of Work/Problem Code: Large Leak. Work Performed/Resolution Code: RP1 Level of Harm - Minimal harm or called MS before leaving. MS stated there was a sprinkler/pipe leak at site and the Fire Alarm Control Panel potential for actual harm (FACP) and alarms were activated. Arrived on site and customer stated there was no fire sprinkler-related leak. The FACP was in alarm. Checked and tested waterflow switch (a water flow detector), adjusted the Residents Affected - Some setting, and checked tamper switch on Post Indicator Valve (PIV - opens/closes the facility water supply from outside the building). Advised customer the FACP is seriously outdated and new panel needs to be installed or this problem will consist of [sic].

During a review of [Vendor Name] Service Request by RP2, dated 7/9/24 at 3 pm, the record indicated Scope of Work/Problem Code: Panel Trouble/Supervisory. Work Performed/Resolution Code: Fire alarm service for PIV. RP1 and RP2 adjusted and tested the switch.

During an interview with MS on 7/10/24 at 3:07 pm, MS stated there had been a malfunction in the fire rise

on 7/9/24 that set off the fire alarm early in the morning. MS stated he set one of the eight fire system zones (Zone 8) to silent until approximately 3 pm on 7/9/24 to stop the alarm.

During concurrent observation of fire control panel behind Nurses' Station 1 and interview with MS on 7/18/24 at 9:58 am, MS stated a local vendor checked the system 7/9/24 because the fire riser (a pipe that connects pressurized water sources and supplies sprinkler system with water) indicated different pressures. MS stated that was the cause of the system alarm that morning. MS stated he switched Zone 8 from Alarm to Disable/Trouble and then pressed the Trouble Silence button, which he stated silenced the alarm for that zone only. MS stated Zone 8 was off from 10 or 11 am to 3 pm on 7/9/24.

During an interview with ADM on 7/18/24 at 2:15 pm, ADM stated he was aware a fire alarm zone had been turned off for several hours on 7/9/24. ADM stated, The machine doesn't turn off. The rest of the building would still alarm. ADM stated a fire watch (continuous observation for fire activity) was not performed. ADM stated he was aware the fire vendor's invoices indicated the fire system was outdated. ADM stated he was awaiting a quote from [Vendor Name] to replace the fire system but would need two different quotes before corporate would fund it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 055656