Health inspection·December 26, 2025

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 maintain a safe, comfortable and homelike environment when Resident 1's bedside table had scratched marks on top and had chipped edges. This failure resulted in Resident 1 feeling angry. On 12/26/25 at 10:40 a.m., an unannounced visit was made at the facility to investigate a complaint allegation. During a phone interview on 12/26/25 at 2:03 p.m., Resident 1 stated when she was living at the facility, her bedside table had scratch marks on top and peeled edges. Further stated she felt angry about this. During a review of Resident 1's Facesheet, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included depression (a mental health disorder characterized by persistently sad mood or loss of interest in activities, causing significant impairment in daily life) and was discharged from the facility on 9/9/25. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 8/11/25 indicated a BIMS (Basic Interview of Mental status) score of 15 (meaning Resident 1 was cognitively intact). During a concurrent observation and interview on12/26/25 at 2:15 p.m., with the Director of Nursing (DON) in the room where Resident 1 used to reside, the bedside table was observed to have scratch marks on top and had chipped edges. The DON described the bedside table as an old furniture. Also, the wall facing the bathroom was observed to have areas of chipped paint. During a concurrent observation and interview on 12/26/25 at 2:33 p.m., with the Maintenance Assistant (MA) in Resident 1's former room, MA described the wall's paint as chipping and stated that the wall with chipped paint had been in that condition for a few months. MA acknowledged that the condition of the room's wall was not homelike. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and home like environment .1. Staff provides person-centered care that emphasizes the residents comfort, independence and personal needs and preferences. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include: .c. inviting colors and decor . 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 2 Event ID: 555872 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 12/26/2025 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)