Health inspection·April 20, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 31's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/9/23 indicated Resident 31 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 12. BIMS score range is from 0-15, with zero as the most impaired. During an interview with Resident 31 on 4/19/23 at 11:39 a.m., Resident 31 stated not being able to accurately recall details about the incident of a staff tearing me to pieces because of a failing memory. Resident 31 stated, it would have been better if questions were asked the same day Resident 31 made the statement. Resident 31 also stated no one from the facility had asked questions about Resident 31's statement. During an interview with ADM on 4/20/23 at 12:49 p.m., ADM stated, statements from residents such as, nurse is tearing me to pieces should be investigated right away to make sure this was not an abuse case. Review of the facility's policy and procedure titled Abuse Prevention and Reporting last revised April 2021 indicated When a resident or someone in behalf of a resident reports a grievance or makes a complaint .thorough investigations are commenced immediately upon presentation of complaint/grievance/event. 2. During an interview and concurrent review of the employee files with the Director of Nursing (DON) on 4/20/23 at 11:05 a.m., files for the following staff were reviewed; a. Certified Nursing Assistant (CNA) 2. b. Restorative Nursing Assistant (RNA). c. Activity Assistant (AA). d. Licensed Vocational Nurse (LVN) 1. e. Activities Director (AD). DON stated, background checks with the Department of Justice (DOJ) were not done for all five employees. DON also stated, for licensed nurses like LVNs and Registered Nurses and CNAs,the facility relied on the background checks being done by respective licensing and certification agencies for both professions. DON stated, for CNA 2, hired on 3/30/22, the facility did not have a copy of their certification on file. There was no documentation that background checks with the DOJ or State Registry were performed for all five employees reviewed. During an interview with ADM on 4/20/23 at 12:49 p.m., ADM stated the facility has not done background checks for all employees, and, for licensed staff, the facility relied on the background checks performed by the respective licensing board or certification agencies. For the unlicensed staff (i.e., activities, kitchen, housekeeping), the facility did reference checks because most were known to be long-time employees of the facility. ADM also stated the facility utilizes information based on Megan's law (penal code that mandates the state DOJ to notify the public about sex offender registrants who pose a risk to public safety). ADM, however, stated that doing reference checks did not give information if the prospective employees were convicted of crimes other than sexual in nature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 2 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy and procedure titled, Abuse Prevention and Reporting last revised April 2021, indicated all applicants for employment have references checked prior to hiring. The policy also indicated three different ways the facility checks for criminal background as follows; - If a license or certification of a staff is deemed active by the licensing or certification agency, the prospective employee is deemed to have had a criminal background check. - Persons who have had a finding entered into the State Registry concerning abuse, neglect, mistreatment and misappropriation of property shall not be hired. - Megan's Law website is checked prior to job offer and after references are checked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 3 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement their Abuse policy and procedure to investigate and report injuries of unknown origin for one (Resident 4) sampled resident. Resident 4's laceration to the left pinky toe was not investigated for the source of the injury and reported to the required agencies. This failure resulted in Resident 4 being transferred to the emergency room (ER) for sutures and had the potential to place residents at risk for mistreatment, neglect and /or abuse. Findings: Review of Resident 4's Significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 1/4/23, indicated Resident 4 had unclear speech with slurred or mumbled word, rarely/never understood. Resident 4 had short and long term memory problem. Resident 4 had no behavioral symptoms. Resident 4's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of the nurses notes dated 2/12/23 indicated Resident 4 laid on his floor mattress, and noted bleeding bright red with deep cut below his left pinky toe. The physician advised staff to send Resident 4 to the ER. During a review of Resident 4's nurses notes and concurrent interview on 4/20/23 at 12:42 p.m., the Director of Nursing (DON) stated Resident 4's laceration to the left pinky toe was an injury of unknown origin. DON stated the facility did not know the cause of the injury. DON further stated it was assumed Resident 4 bumped his leg on the wall or chair. DON said the facility did not investigate Resident 4's left pinky toe laceration or report to the Department. Review of the nurse's note dated 2/13/23, indicated Resident 4 returned from the ER with stitches to the left pinky toe laceration. Review of the facility's policy and procedure titled, Investigating Resident Injuries, revised April 2021, indicated if the nursing and medical assessment determines an injury of unknown source, the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. Review of the facility's policy and procedure, Abuse, revised and approved November 2022, indicated investigations of suspected abuse or suspicious circumstances or injuries/accidents of known or unknown origin require reporting. The Administrator reports, as indicated, to the appropriate agency: i. California Department of Public Health, licensing and Certification (DPHS L&C) - Supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 4 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents when: 1. For Resident 99, Metformin (diabetic medication), a condition where blood sugar levels are too high) was not available for medication administration. 2. For Resident 149, Fluticasone propionate nasal suspension (for management of nasal symptoms of perennial nonallergic rhinitis in adults, rhinitis is inflammation that causes nasal congestion, runny nose, sneezing and itching) was not available for medication administration. [Reference:https://dailymed.nlm.nih.gov] These failures had the potential to result in an ineffective medication regimen. Findings: 1. Review of Resident 99's admission Record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 4/18/23 at 8:42 a.m., LVN 2 did not administer Metformin 500 milligrams (mg) tablet to Resident 99. LVN 2 stated Resident 99's Metformin was not available for administration. Review of Resident 99's Medication Administration Record (MAR) for April 2023 indicated, on 4/18/23, Resident 99's Metformin dose scheduled for 9 a.m. was not administered. During a follow-up interview and concurrent review of the clinical record, with LVN 2 on 4/18/23 at 1:22 p.m., LVN 2 stated Resident 99's Metformin was last administered 4/17/23 and the request for refill was sent 4/17/23. 2. During an observation on 4/18/23 at 11:24 a.m., Registered Nurse (RN) 1 administered Resident 149's scheduled morning medications except Fluticasone Propionate nasal suspension. During an interview with RN 1 on 4/18/23 at 11:49 a.m., RN 1 stated she could not find Resident 149's Fluticasone spray in either of the two medication carts and would call the pharmacy to order for a refill. Review of Resident 149's clinical record indicated Resident 149 was admitted to the facility on [DATE] with multiple diagnoses that included dyspnea (difficulty breathing). Resident 149's Order Summary Report as of 4/19/23 indicated for Resident 149 to receive Fluticasone Propionate Nasal Suspension 50 microgram per actuation (mcg/act) two sprays in each nostril daily. During an interview with RN 2 on 4/19/23 at 10:06 a.m., RN 2 stated regular prescription medications should be ordered a few days before they run out. RN 2 stated the medication card has a blue line that would signal the licensed nurse to send the refill request to the pharmacy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 5 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0755 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure titled, Medication Ordering and Receiving From Pharmacy Provider copyrighted 2007 indicated all medications shall be reordered in advance by faxing or transmitting the order to the pharmacy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 6 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 43's admission Record indicated Resident 43 has been known to the facility since 4/30/22 with diagnoses that included dementia (loss of mental functions severe enough to affect daily life) and hallucinations. Residents Affected - Some Review of Resident 43's Order Summary Report as of 4/20/23 indicated for Resident 43 to receive quetiapine fumarate tablet (Seroquel, treats psychosis, a mental illness that cause abnormal thinking and perceptions) 50 milligrams by mouth at bedtime for other hallucinations. [Reference:https://medical-dictionary.com/]. Review of Resident 43's hallucination care plan dated 4/17/23 indicated the goal was for Resident 43 to have fewer episodes of hallucinations by review date 9/3/23. Interventions included for staff to administer Seroquel as ordered and monitor effectiveness and monitor hours of sleep during night shift. During an interview and concurrent review of Resident 43's clinical record with DON, on 4/20/23 at 12:11 p.m., DON stated Resident 43's MAR for April 2023 did not indicate monitoring for medication effectiveness. DON stated the MAR did not identify what type of hallucinations the staff were monitoring for. DON also stated the MAR did not indicate monitoring for hours of sleep at night. Review of the Social Services assessment dated [DATE] indicated, The resident mentions the hallucinations are not distressing to her. Review of Interdisciplinary Team (IDT, group composed of individuals representing different departments in the facility) Progress Notes dated 11/23/33 indicated .no mood indicators at this time. Another IDT Progress Note dated 3/30/23 indicated Resident 43 had improvement with mood and activities of daily living. Both IDT Notes did not indicate monitoring for hallucinations and hours of sleep. Based on interviews and record reviews, the facility failed to ensure four (Residents 4, 28, 41 and 43) of five sampled residents were free from unnecessary drugs when; - Resident 4 was administered two antipsychotic medications, Risperdal and Zyprexa, without adequate clinical indication for use and monitoring for adverse side effects. Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior. - Resident 28 was administered Clozapine an antipsychotic and Sertraline an antidepressant without adequate monitoring for target behavior and adverse side effects. Antidepressants are medications used to treat major depressive disorder, some anxiety disorders and chronic pain conditions - Resident 41 was administered Mirtazepine (anti-depressant) for sleep without adequate monitoring the hours of sleep. to determine effectiveness. -For Resident 43,the indication for use of Seroquel an antipsychotic was not monitored. These failures had the potential for residents to receive unnecessary drugs and adverse medication side effects. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 7 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0757 Level of Harm - Minimal harm or potential for actual harm According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidal not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). Residents Affected - Some [Reference: https://www.drugs.com/pro/risperdal]. 1. Review of Resident 4's significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 1/4/23, indicated Resident 4 had unclear speech with slurred or mumbled word, rarely/never understood. Resident 4 had short and long term memory problems. Resident 4 had no behavioral symptoms and diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of the physician orders indicated Resident 4 was prescribed the following medications : - Risperdal tablet 1 mg (milligram) by mouth daily for anoxic (oxygen deprived) brain damage manifested by poor impulsive control to leave out of exit doors unattended. - Zyprexa tablet 10 mg, give 1 tablet by mouth two times a day for poor impulse control manifested by poor judgement, no safety awareness, limited self awareness. Review of the Medication Administration Record (MAR), dated February, March and April 2023, indicated Resident 4 was administered Risperdal tablet 1 mg by mouth daily for poor impulsive control to leave out of exit doors unattended and Zyprexa tablet 10 mg give 1 tablet by mouth two times a day for poor impulse control manifested by poor judgement, no safety awareness, limited self awareness. Further review of Resident 4's MARs, dated February, March and April 2023, indicated adverse side effects for Risperdal and Zyprexa use were not monitored. During an interview on 4/18/23 at 11:23 a.m., the Certified Nursing Assistant (CNA 1) stated Resident 4 had no behavior, no agitation and sleeps most of the time. During an interview on 4/19/23 at 10:31 a.m., the Consultant Pharmacist (CP) stated he identified the inadequate clinical justification and discussed Resident 4's use of Risperdal for poor impulse control to leave out of exit door unattended with the facility's interdisciplinary team. CP could not provide a Medication Regimen Review (MRR) documentation that addressed his concern for Resident 4's use of Risperdal and Zyprexa. 2. Review of Resident 28's Minimum Data Set, Resident Assessment and Care Screening, dated 3/14/23, indicated Resident 28 had unclear speech with slurred or mumbled word, rarely/never make self understood or understand others. Resident 28 had short and long term memory problems. Resident 28 had no behavioral symptoms and had trouble falling asleep and little energy. Resident 28 diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), depression and anxiety. Review of the Physician Orders indicated Resident 28 was prescribed the following medications : - Clozapine tablet 25 mg give 2.5 tablet by mouth in the evening for major depression and generalized anxiety disorder severe psychotic features. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 8 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0757 - Sertraline HCL tablet mg give 3 tablet by mouth one time a day for depression. Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record (MAR), dated February, March and April 2023, indicated Resident 28 was administered Clozapine tablet 25 mg give 2.5 tablet by mouth in the evening for major depressive and generalized anxiety disorder with severe psychotic features and Sertraline HCL (hydrochloride) tablet 50 mg give 3 tablet by mouth one time a day for depression. Residents Affected - Some Further review of Resident 28's MARs, dated February, March and April 2023, indicated target behaviors and adverse medication side effects were not monitored for usage of Clozapine and Sertraline. During an interview on 4/19/23 at 10:07 a.m., Registered Nurse (RN 1) stated Resident 28's behavior manifestation included scratching CNAs during brief changes. RN 1 stated side effects of Clozapine and Sertraline are monitored in the electronic medical records. RN 1 could not provide documentation that Resident 28 target behaviors manifestation and adverse side effects were monitored. 3. Review of Resident 41's Significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 3/3/23, indicated Resident 41 had unclear speech with slurred or mumbled word, rarely/never make self understood or understand others. Resident 41 had short and long term memory problem. Resident 41 had no behavioral symptoms. Resident 41 trouble falling asleep and little energy. Resident 41 diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language) and depression. Review of the Physician Orders indicated Resident 41 was prescribed Mirtazapine 15 mg tablet, give 2 tablet by mouth at bedtime for sleep related to major depression Review of the Medication Administration Record (MAR), dated February, March and April 2023, indicated Resident 41 was administered Mirtazapine 15 mg at bedtime for sleep Further review of Resident 41's MARs, dated February, March and April 2023, indicated hours of sleep before and after the administration of Mirtazepine for sleep and adverse medication side effects were not monitored. During an interview on 4/19/23 at 10:07 a.m., Registered Nurse (RN 1) stated Resident 28's target behaviors and side effects of Resident 28 and 41's use of psychotropic medications are monitored in the electronic medical records. RN 1 could not provide documentation that Residents 4, 28 and 41's target behaviors and adverse side effects were monitored. During an interview on 4/19/23 at 10:31 a.m., the Consultant Pharmacist (CP) stated he did not identify Residents 4, 28 and 41's behavior manifestation and adverse side effects were monitored for use of psychotropic medications during the monthly MRR. During an interview on 4/20/23 at 8:42 a.m., Director of Nursing (DON) stated facility used the 24 hour report hurdle to monitor residents target behaviors for psychotropic medication use. DON could not provide documentation that behaviors and adverse side effect are monitored for Resident 4, 28 and 41 use of psychotropic medications. The facility's policy and procedure, titled, Medication Regimen Reviews (MRR), revised May 2019 indicated; The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 9 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0757 example: Level of Harm - Minimal harm or potential for actual harm a. medication ordered in excessive doses or without clinical indication; b. medication regimens that appear inconsistent with resident's stated preferences; Residents Affected - Some c. duplicate therapies or omissions of ordered medications; d. inadequate monitoring for adverse consequences. The facility's policy and procedure, titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019 indicated; When medications are prescribed for behavioral, documentation will include; rationale for use, potential underlying causes of behavior, other approaches and interventions tried prior to the use of antipsychotic medication, specific target behaviors and expected outcomes and monitoring for efficacy and adverse consequences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 10 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to be free of medication error rate of five percent or greater when three medication errors were observed out of 31 opportunities. The medication error rate was calculated as follows; three divided by 31, then multiplied by 100, which was equal to 10 percent. Residents Affected - Few This failure had the potential to result in ineffective medication regimen for the affected residents (Residents 99 and Resident 149). Findings: 1. Review of Resident 99's admission Record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (when blood sugar levels are too high). During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 4/18/23 at 8:42 a.m., LVN 2 did not administer Metformin (treats diabetes) 500 milligrams (mg) tablet to Resident 99. LVN 2 stated Resident 99's Metformin was not available for administration. Review of Resident 99's Medication Administration Record (MAR) for April 2023 indicated an order with a start date of 4/8/23 for Metformin 500 mg by mouth two times daily for glucose (blood sugar) control, give with breakfast and dinner, scheduled at 9 a.m. and 5 p.m. The MAR indicated 9 a.m. dose for 4/18/23 was not administered. 2. During an observation on 4/18/23 at 11:24 a.m., Registered Nurse (RN) 1 administered Resident 149's scheduled morning medications except Fluticasone Propionate nasal suspension (for management of nasal symptoms of perennial nonallergic rhinitis (runny nose) in adults). [Reference:https://dailymed.nlm.nih.gov]. During an interview with RN 1 on 4/18/23 at 11:49 a.m., RN 1 stated she could not find Resident 149's Fluticasone spray in either of the two medication carts and would call the pharmacy to order for a refill. Review of Resident 149's MAR for April 2023 indicated Fluticasone was signed off (administered). During a follow-up interview and concurrent review of Resident 149's MAR with RN 1, on 4/18/23 at 12:09 p.m., RN 1 stated she did not administer Fluticasone but signed it off on the MAR. RN 1 stated she had to strike off her initials from the MAR after finding out the medication was not available. Review of Resident 149's clinical record indicated Resident 149 was admitted to the facility on [DATE] with multiple diagnoses that included dyspnea (difficulty breathing). Resident 149's Order Summary Report as of 4/19/23 indicated for Resident 149 to receive Fluticasone Propionate Nasal Suspension 50 microgram per actuation (mcg/act) two sprays in each nostril daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 11 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to promptly follow-up on a denture evaluation and acquiring full dentures for one (Resident 8) sampled resident in a timely manner. Residents Affected - Few This failure resulted in emotional distress. Findings: Review of the significant change in status- Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 4/2/23, indicated Resident 8's Basic Interview of mental status (BIMS) score was 15 (meaning cognitive intact). Resident 8 had a clear speech, able to express ideas and wants. Resident 8 had no natural teeth. Resident 8 had diagnoses that included stroke. Resident 8's insurance was Medicaid. During an interview on 4/17/23 at 10:24 a.m., Resident 8 stated he felt so depressed because he had no dentures to eat food. Review of the care plan revised 2/3/23 indicated Resident 8 had several teeth extracted and new dentures are on hold. During an interview on 4/17/23 at 12:06 p.m., the Social Services Designee (SSD) stated Resident 8 had all his teeth extracted sometime ago and had no dentures. SSD stated there seems to be some issues with Resident 8's insurance payment that delayed Resident 8's dentures. The facility's policy and procedure, Dental services, revised December 2016 indicated, Social Services representative will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 12 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review, the facility failed to ensure storage of food under sanitary conditions when: Residents Affected - Some - Dietary staff's lunch bag was kept in the kitchen refrigerator. - One container of low-fat cottage cheese was opened and not labeled or dated - One bottle of chili garlic sauce open date 2/28/23 - One bottle salad cream opened 8/3/22 - One bottle spicy sauce opened 2/28/23 - 1/2 sliced apple in cup not labeled or dated - Two bottles of jam opened 3/6/23 These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 4/17/23 at 9:19 a.m., and accompanied by the Director of Food and Nutrition Services (DFNS), one staff lunch bag was stored in the refrigerator, One container of low fat cottage cheese opened not labeled or dated, one bottle of chili Garlic sauce opened 2/28/23, one bottle salad cream opened 8/3/22, one bottle spicy sauce opened 2/28/23, half sliced apple in cup not labeled or dated, two bottles of jam opened 3/6/23. During an interview on 4/18/23 at 9:36 a.m., [NAME] (CK) stated the dietician gave him training every so often about dating and labeling food items when opened and placed in the refrigerator. During an an interview on 4/18/23 at 9:51 a.m., DFNS stated the lunch bag was her bag. The facility's policy and procedure, titled, Cover, Label and Date items for storage, undated, indicated, All employees of Food and Nutritional Services (FSN) are responsible for covering, labeling and dating all food stored in the kitchen. All food not used by the appropriate date must be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 13 of 14 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 555872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chaparral House 1309 Allston Way Berkeley, CA 94702 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to coordinate care planning in collaboration with the resident, family and hospice care (provisions for the terminally ill) provider for one (Resident 41) sampled resident. This failure had the potential for residents to not receive person-centered care at the end-of-life. Findings: Review of Resident 41's significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 3/3/23, indicated Resident 41 had unclear speech with slurred or mumbled word, rarely/never make self understood or understand others. Resident 41 had short and long term memory problem. Resident 41 had no behavioral symptoms. Resident 41 had trouble falling asleep and little energy. Resident 41 diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), depression and on hospice care (is a type of care that focuses on interdisciplinary approach to specialized nursing care for people with life limiting illnesses, available to people with a life expectancy of six months or less, does not focus on treatments to cure the cause of the terminal illness. It seeks to keep the individual comfortable and make their remaining time as meaningful as possible). Review of order summary report, dated 2/27/23, indicated Resident 41 was admitted to hospice care on 2/25/23. During an interview and concurrent care plan review on 4/19/23 at 10:51 a.m., Registered Nurse-MDS-Care Coordinator (MDS), stated the facility's Interdisciplinary Team (IDT) had not met with hospice representatives to coordinate a care planning conference with Resident 41 and family, including the hospice provider. During an interview on 4/19/23 at 11:19 a.m., the Social Service Designee (SSD), stated the facility had not coordinated and scheduled the care planning conference with Resident 41 and family with the hospice representative. During an interview on 4/20/23 at 9:11 a.m., the Director of Nursing (DON) stated the facility practice was to coordinate care planning with the hospice provider when residents are started on hospice care. The facility's policy and procedure, Hospice Program, revised July 2017, indicated for staff to implement, Coordinated care plans for residents receiving hospice services provided by our facility including the responsible provider and discipline assigned to specific tasks in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555872 If continuation sheet Page 14 of 14