Health inspection·June 12, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide six of 12 Residents (Resident 35, Resident 13, Resident 28, Resident 8, Resident 16, and Resident 9) with dignity and respect when they were not served their lunches at the same time as others seated at their dining table. For Resident 13, utensils were not provided in a timely manner. These failures had the potential to result in Resident 35, Resident 13, Resident 28, Resident 8, Resident 16, and Resident 9 having a decreased quality of life. Findings: 1. A record review of the face sheet dated 6/12/19 indicated Resident 35 was admitted to the facility on [DATE] with multiple diagnoses including, Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and Alzheimer's Disease (a progressive mental deterioration). 2. The record review of the face sheet dated 6/12/19 indicated Resident 13 was admitted to the facility on [DATE] with multiple medical diagnoses including, Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury) and Major Depressive Disorder. 3. A record review of the face sheet dated 6/12/19 indicated Resident 28 was admitted to the facility on [DATE] with multiple medical diagnoses including, Dementia, Weakness, Abnormal Weight Loss, and Broken Left Arm. 4. The record review of the face sheet dated 6/12/19 indicated Resident 8 was admitted to the facility on [DATE] with multiple medical diagnoses including, Dementia, Alzheimer's Disease, and history of falling. 5. A record review of the face sheet dated 6/12/19 indicated Resident 20 was admitted to the facility on [DATE] with multiple medical diagnoses including, Dementia, Adult Failure to Thrive (a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and Major Depressive Disorder. 6. The record review of the face sheet dated 6/12/19 indicated Resident 9 was admitted to the facility on [DATE] with multiple medical diagnoses including, Dementia and Major Depressive Disorder. During an observation on 6/10/19 at 12:57 p.m., Resident 31 was served food while table mate Page 1 of 5 555872 555872 06/12/2019 Chaparral House 1309 Allston Way Berkeley, CA 94702

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 35 was not; Resident 19 was served food while table mates Resident 13 and Resident 28 were not; Resident 10 and Resident 2 were served food while table mates Resident 8 and Resident 20 were not; and Resident 16 was served food while Resident 9 was not. In addition, Resident 13 sat with food in front of her for 12 minutes before utensils were provided. During an interview on 6/10/19 at 1:33 p.m. with the Activities Assistant 1 (AA 1), she stated the kitchen sends out two carts that are not specifically for certain dining tables, and we (staff) deliver them the way they come out of the kitchen. During an interview on 6/10/19 at 2 p.m. with the Certified Nurse Assistant 1 (CNA 1), she stated we do not decide when trays come out or in what order .that is done by the kitchen. CNA 1 stated the residents should have utensils before the food is served, and was not sure why Resident 13 did not have utensils for her meal. According to the policy, Meal Service-Tray Assembly dated 2018, Service staff should check trays before leaving the kitchen to ensure that the tray is complete with proper service ware, condiments, and meal items. During an interview on 6/10/19 at 2:45 p.m. with the Director of Staff Services (DSD), she stated food and resident trays are supposed to be delivered in the dining room by table, so everyone at one table receives their food at approximately the same time. A record review of the policy and procedure, Meal Service-Delivery of Food Carts and Tray Service dated 2018, Meals will be delivered to residents/patients in a timely manner . Nursing service is responsible for the delivery of trays to the resident's/patient's room or individual table in the dining room. 555872 Page 2 of 5 555872 06/12/2019 Chaparral House 1309 Allston Way Berkeley, CA 94702

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,, interview and record review, the facility failed to ensure two (Resident 19 and Resident 5) of two sampled residents, who were dependent on staff for meals, were not assisted to eat in a timely manner. Resident 19 did not receive meal assistance for ten minutes and had interrupted meal assistance when offered, and Resident 5 did not receive assistance for 35 minutes. Residents Affected - Few This deficient practice resulted in Resident 19 and Resident 5 receiving delayed meal assistance and had the potential for foods to be served cold. Findings: 1. According to the face sheet dated 6/12/19, Resident 19 was admitted to the facility on [DATE] with multiple diagnoses including, Cachexia (weakness and wasting of the body due to severe chronic illness), and Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury). The record review of the Minimum Data Set (MDS-a resident assessment tool) dated 4/12/19, Resident 19 was unable to complete the Brief Interview for Mental Status (BIMS), and required one-person physical assistance for eating. A record review of the document, Weights and Vitals Summary dated 6/2/19 reflected Resident 19 weighed 46.2 pounds. According to Resident 19's Care Plan titled, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Limited Mobility, Impaired balance dated 5/6/19 and indicated she is dependent on staff for all meals. 2. The record review of the face sheet dated 6/12/19 indicated Resident 5 was admitted to the facility on [DATE] with multiple medical diagnoses including, Dementia, Vitamin D Deficiency, and Dysphasia (difficulty swallowing). A record review of the MDS dated [DATE] reflected Resident 5 had a BIMS score of eight out of 15 and required one-person, physical assistance for eating. The record review of the Care Plan dated 5/8/19 indicated Resident 5 was prone to unplanned/unexpected weight fluctuations. During an observation of the main dining room, on 6/10/19 at 12:57 p.m., staff placed the meal tray in front of Resident 19, uncovered it, and walked away. The Certified Nurse Assistant 1 (CNA 1) returned ten minutes later to provide Resident 19 with a sip of liquid and two bites of food before leaving Resident 19 again to serve more trays to other residents in the dining room. CNA 1 returned eight minutes later to finish assisting Resident 19 with the meal. During this same observation time, staff placed the meal tray in front of Resident 5, uncovered the plate, and walked away. Resident 5 waited 35 minutes with the uncovered plate of food. After 35 minutes, a visitor arrived for Resident 5 and assisted Resident 5 with the meal. 555872 Page 3 of 5 555872 06/12/2019 Chaparral House 1309 Allston Way Berkeley, CA 94702

F 0677 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/10/19 at 1:33 p.m. with the Activities Assistant 1 (AA 1), she stated meals are not delivered in a specific order or by table. During an interview on 6/10/19 at 2 p.m., CNA 1 stated we (staff) have to get trays when they come out, even if we are doing something else. CNA 1 further stated they cannot feed everyone at the same time. Residents Affected - Few During an interview on 6/10/19 at 2:45 p.m. with the Director of Staff Services (DSD), she stated the residents are supposed to be fed as soon as their tray comes out of the kitchen, and the food should be delivered to one table at a time. According to the policy and procedure, Meal Service-Deliver of Food Carts and Tray Service dated 2018, Procedures: 1. Tray carts will be served one at a time and staggered to ensure residents/patients receive hot foods and allows nursing to properly assist or feed residents/patients .2 Resident/patients requiring total assistance with meals should be grouped and staggered according to the nursing staff ability to provide service. 555872 Page 4 of 5 555872 06/12/2019 Chaparral House 1309 Allston Way Berkeley, CA 94702

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored properly when food items were left unlabeled and undated in the kitchen refrigerator, and the dishes and utensils were not cleaned under sanitary conditions when the high temperature dishwasher's final rinse did not reach 180 degrees Fahrenheit (F) according to the policy. These deficient practices placed the residents at risk for developing foodborne illness. Findings: During the initial observation of the dietary department on 6/10/19 at 8:14 a.m., the kitchen refrigerator had one container of cream cheese, one package of cinnamon french toast, one loaf of bread, four hamburger buns, four English muffins, and one bag of pita bread left opened, unlabeled and undated. There was one five-pound container of low-fat cottage cheese that had a use-by date of 6/9/19. During a concurrent interview with the Cook, she stated all items in the refrigerator should be labeled and dated when opened, and all expired food items should be discarded. A record review of the policy, Refrigerated Storagedated 2018 indicated, Leftover food or unused portions of packaged foods should be covered, labeled and dated. During an observation and concurrent interview on 6/10/19 at 8:52 a.m., in the kitchen, Dietary Aide (DA) 1 placed a load of dishes into the high temperature dishwasher. The wash cycle temperature gauge indicated 168 degrees F, and the final rinse cycle temperature was 155 degrees F. DA 1 stated the final rinse temperature should be a minimum of 180 degrees F. During an observation on 6/10/19 at 8:57 a.m. in the kitchen, DA 1 placed a load of dishes in the dishwasher. The wash cycle temperature observed at the gauge read 165 degrees F, and the final rinse cycle temperature observed at the gauge read 150 degrees F. During a phone interview with the Dietary Supervisor (DS) on 6/10/19 at 2:22 p.m., she stated the dishwasher should be rinsing at 180 degrees F. DS further stated if the temperature does not reach 180 degrees F, then bacteria might be left on the dishes and utensils, and residents could potentially get sick. Review of the policy, Dishwashing Procedures (Dishmachine) dated 2018 indicated, Conventional high temperature dish-machines must reach a water temperature of 150-165 degrees F for wash cycle and 180 degrees F at the manifold in the final rinse . 555872 Page 5 of 5