Health inspection·January 28, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure one of 12 sampled residents (Resident 19)'s room was homelike, when Resident 19's room had multiple paint nicks, black scrapes on the wall. This failure resulted in Resident 19 feeling depressed and feeling her environment was not homelike. Findings: During a record review of Resident 19's admission Record dated 1/27/22 which indicated Resident 19 was admitted on [DATE]. During a record review of Resident 19's Minimum Data Set (MDS, an assessment tool used to guide care) dated 12/14/21, the MDS indicated Resident 19's Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score was 14, meaning no cognitive impairment. During a concurrent observation and interview on 1/25/22, at 2:12 p.m., in Resident 19's room, there were black scrape marks on the lower end of all four walls. There were white patches of paint on both sides of at the head and foot of the bed. Resident 19 stated the walls were dirty and had black markings and chipped paint. Resident 19 stated her room was not homelike for her and it made her feel depressed. During a subsequent interview on 1/27/22, at 9:56 a.m., Resident 19 stated the walls with dirty, black markings and chipped paint had been there since she was admitted to the facility. Resident 19 stated she asked the facility staff to repair the walls in her room. During a concurrent observation and interview on 1/27/22, at 9:36 a.m., in Resident 19's room, with Maintenance Supervisor (MS), MS stated the walls had a good amount of black abrasions (scrapes) and paint nicks. MS stated that it was not okay to have resident's rooms with chipped paint or markings because it is the resident's right to have a clean house and could make the residents feel uncomfortable and want to leave the facility. During a record review of the facility's policy and procedure (P&P) titled, Homelike Environment, and revised 02/2021 indicated, Residents are provided with a safe, clean, comfortable and homelike environment . Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 555082 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555082 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546 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)