Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chaparral House during CMS and state inspections, most recent first.
Failure to Provide Required Advance Discharge Notice: The facility did not provide proper 30-day written NPTD notice for four residents. Two residents received only 3 and 8 days' notice before discharge, and two residents were not given the NPTD during their stay. The SSD and DON both stated the residents should have received 30-day advance notice, consistent with facility policy and federal regulation.
Failure to provide ongoing psychosocial monitoring after an abuse allegation: A resident with depression and intact cognition reported that a male CNA touched her inappropriately, but after an IDT note stating the SSD would continue to follow up and provide emotional support, there was no further documentation that social services revisited the resident. The ISSD and DON stated that residents should be monitored for psychosocial distress for at least 72 hours after an abuse allegation.
Failure to Explain Medicaid Share of Cost Before Eviction Notice: A resident with intact cognition and diagnoses including epilepsy, insomnia, and gait/mobility abnormalities was told about unpaid Medicaid share of cost and a pending discharge, but the charge was not fully explained by business office staff and/or the SSD. The SSD could not provide documentation that the share of cost was explained before the initial eviction notice was issued, despite the resident stating the amount was not clearly understood.
Failure to Report and Document Resident Property Loss: A resident with intact cognition and a BIMS of 15 reported that $5,000 was stolen from her room. The SSD said he filed a police report but could not provide proof, a case number, or the officer’s name, and the facility’s theft and loss log was blank with no record of the missing money. The only documentation noted the SSD was investigating, while the ombudsman was notified and law enforcement was not checked as informed.
A resident with depression and intact cognition reported feeling angry about having a bedside table with scratch marks and chipped edges. During an unannounced visit, surveyors observed the damaged furniture and chipped paint in the room, which staff acknowledged had been in poor condition for months and did not meet homelike standards.
A nurse administered Percocet instead of the prescribed Norco to a resident with a right femur fracture, after mistakenly selecting the wrong medication from the E-kit. The error was confirmed by the DON and Pharmacist Consultant, and documentation showed that facility policy requiring triple-checking of medication labels was not followed.
Three residents requiring full assistance with meals were not offered or fed their bread rolls during lunch. An RN asked a resident if she wanted her bread roll, but due to the lack of gloves, offered water instead. The Director of Staff Development acknowledged the oversight, which contradicted the facility's policy on dignity and potentially affected the residents' well-being.
A facility failed to ensure appropriate use of psychotropic medications for three residents. One resident was prescribed Seroquel without proper indications, another had a PRN Ativan order without a stop date, and a third was given Trazadone for insomnia without monitoring sleep hours. The DON acknowledged these deficiencies, which were against the facility's policies.
The facility did not follow the established menu for residents on soft and bite-sized and easy to chew diets, affecting 12 residents. The Dietary Services Supervisor forgot to serve the required two ounces of gravy with the baked chicken, as specified in the facility's Therapeutic Spreadsheet Menu. This oversight was acknowledged by the DSS and was contrary to the facility's policy to meet dietary guidelines.
The facility failed to ensure sanitary food preparation and storage practices, as evidenced by a dirty can opener, unclean kitchen floors, and an oven with grime build-up. Additionally, the dry storage area had food crumbs and dead ants, and a Diet Aide did not wear a beard net during meal preparation. These issues were acknowledged by the Dietary Service Supervisor and Registered Dietician, highlighting a lapse in adherence to the facility's sanitation policies.
A resident with a brief psychotic disorder was admitted to the facility without undergoing the required PASARR evaluation, which is necessary to determine the appropriateness of their placement and mental health services. The absence of this evaluation was confirmed by the Medical Record Director, and the facility's Administrator acknowledged the oversight.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan did not address their Major Depressive Disorder, Insomnia, or the use of prescribed medications. Another resident's care plan did not address a hairy mole on their chin, despite the resident's request for hair removal and acknowledgment by staff. The Director of Nursing confirmed the absence of necessary care plans, contrary to facility policy.
A resident with memory problems and multiple health conditions, including Peripheral Artery Disease and Non-Alzheimer's Dementia, did not receive podiatry care for long toenails as ordered by the physician. The facility's policy required referral to qualified professionals for foot disorders, but the resident's scheduled podiatry care was missed, resulting in a deficiency.
A resident with Non-Alzheimer's Dementia and a right hand contracture did not receive the prescribed splint application, as observed by surveyors. Despite a physician's order and a care plan for a restorative program, staff interviews revealed that the resident had not been on the program for some time and had not used a splint recently. The facility's policy to maintain or improve residents' ability to carry out activities of daily living was not followed.
A facility failed to have a written contract with a dialysis provider for a resident with acute kidney failure requiring outpatient hemodialysis. Despite the resident's regular dialysis appointments and intact cognition, the facility administrator admitted to not having contracts with the dialysis provider or transportation company, acknowledging the regulatory requirement but not yet fulfilling it.
Two residents were found with call lights out of reach, posing a risk of unmet needs. One resident's call button was nearly touching the floor, while another's was on the floor. A CNA and LVN confirmed the issue, and the DON stated that call lights should always be accessible. The facility's policy requires call lights to be within reach.
Failure to Provide Required Advance Discharge Notice
Penalty
Summary
The facility failed to provide proper discharge notice for four sampled residents. Resident 2, admitted with cervical disc disorder, received a Notice of Proposed Transfer and Discharge (NPTD) dated 4/13/26 with a planned discharge date of 4/16/26, giving only 3 days' notice. Resident 5, admitted with rhabdomyolysis, received an NPTD dated 4/28/26 with a planned discharge date of 5/6/26, giving only 8 days' notice; the record also showed Resident 5 was discharged home on 5/6/26. Resident 3 was admitted with a fractured left femur and a history of falling, and Resident 4 was admitted with a fractured left femur and a history of falling. During concurrent record review and interview, the SSD stated that Resident 3 and Resident 4 were not given the NPTD during their facility stay. The SSD also stated that Residents 2, 3, 4, and 5 should have been given the NPTD 30 days prior to discharge to allow adequate time for safe relocation planning and for families to find an appropriate new home. The DON stated that Residents 2, 3, 4, and 5 should have been given the NPTD 30 days prior to discharge because it was the federal regulation. The facility policy stated residents and/or representatives are to be notified in writing, in a language and format they understand, at least 30 days prior to transfer or discharge.
Failure to Provide Ongoing Psychosocial Monitoring After Abuse Allegation
Penalty
Summary
Medically-related social services were not provided to ensure ongoing psychosocial monitoring for a resident after she reported a sexual abuse allegation. The resident was admitted with diagnoses that included depression, and her MDS showed a BIMS score of 15, indicating she was cognitively intact. On 6/24/26, the resident told nursing staff that she had been touched inappropriately by a male CNA, although she did not provide additional details about the allegation. The record showed an IDT note on 6/25/26 documenting that the previous SSD would continue to follow up with the resident to provide emotional support, but no further documentation was found showing that the SSD revisited the resident after that note. During interview, the ISSD stated that after a resident reports an allegation of abuse, the resident is monitored by social services for psychosocial distress for at least 72 hours, and the DON stated that following an allegation of abuse, a resident should have psychosocial monitoring for at least three days. The facility policy stated that social services are provided to help each resident attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Failure to Explain Medicaid Share of Cost Before Eviction Notice
Penalty
Summary
The facility failed to notify Resident 1 of the Medicaid share of cost in a timely manner and did not explain the charge in a way the resident could easily understand. Resident 1 was admitted to the facility with diagnoses including epilepsy, insomnia, and abnormalities of gait and mobility, and a later MDS showed a BIMS score of 15, indicating intact cognitive function. During an interview, Resident 1 stated that the Social Services Director had given a pending discharge date and that the facility had informed the resident of money owed for several months of unpaid share of cost, but that the charge was not fully explained by business office staff and/or the SSD. During a concurrent interview and record review, the SSD reviewed Resident 1's facility invoice and stated that the resident had not paid the share of cost since 7/1/25. The SSD said the initial eviction notice was given on 4/6/26 and a second notice on 6/19/26, but was unable to provide documentation that the Medicaid share of cost charges were explained to Resident 1 before the initial eviction notice was issued. The facility policy titled Facility-Initiated Transfer/Discharge Policy stated that the facility shall protect each resident's right to remain in the facility and shall not transfer or discharge any resident except as permitted under federal and California law.
Failure to Report and Document Resident Property Loss
Penalty
Summary
The facility failed to ensure timely reporting and a thorough investigation of an allegation of misappropriation of resident property for one resident. The resident was admitted with diagnoses including hyperlipidemia and acute on chronic diastolic heart failure. Her MDS dated 3/6/26 showed she was able to understand others and make herself understood, and her BIMS score was 15 out of 15, indicating no impaired cognition. During interview, the resident stated she told the SSD several weeks earlier that $5,000 was stolen from her room, that he told her he would file a police report, and that she never received a copy of any report or spoke with a police officer about the missing money. The SSD stated he filed a police report but could not provide the officer’s name, a case number, or proof that law enforcement was notified. The facility’s Resident Theft and Loss Record was blank and did not include the resident’s reported missing $5,000, and the SSD stated he was unable to provide any completed theft and loss records from the past year. The only documentation in the resident’s record was an interdisciplinary progress note stating the SSD was investigating the missing money, and the Report of Suspected Dependent Adult/Elder Abuse showed the ombudsman was informed but the law enforcement box was not checked. The DON stated she was not informed of the allegation, and the facility’s Lost and Found policy required missing items to be reported to the DON and records to be maintained for one year.
Failure to Maintain Homelike Environment Due to Damaged Furniture and Chipped Paint
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for a resident whose bedside table had scratch marks on top and chipped edges. The resident, who had a diagnosis of depression and was cognitively intact according to her MDS assessment, reported feeling angry about the condition of her bedside table during her stay. The deficiency was identified during an unannounced visit, where the resident described her dissatisfaction with the furniture in her room. Further observations in the resident's former room, conducted with the DON and Maintenance Assistant, confirmed the presence of scratched and chipped furniture as well as chipped paint on the wall facing the bathroom. The Maintenance Assistant acknowledged that the chipped paint had been present for several months and agreed that the room's condition was not homelike. Review of the facility's policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment, emphasizing person-centered care and inviting decor, which was not met in this instance.
Medication Error: Incorrect Opioid Administered from E-Kit
Penalty
Summary
A medication error occurred when a nurse administered Percocet (oxycodone/acetaminophen) instead of the prescribed Norco (hydrocodone/acetaminophen) to a resident who had been admitted with a right femur fracture and was experiencing severe pain. The physician's order specified Norco 10/325 mg to be given every four hours as needed, but on the specified date, two doses of Percocet 10/325 mg were taken from the emergency kit (E-kit) and given to the resident. This error was acknowledged by the Director of Nursing (DON) and was documented in both an incident report from the pharmacist and a facility post-event review, which confirmed that the wrong medication was removed and administered from the E-kit. Interviews with facility staff, including the DON and the Pharmacist Consultant, confirmed that the nurse failed to follow the facility's medication administration policy, which requires checking the medication label three times to ensure the right resident, medication, dosage, time, and route. The incident exposed the resident to the risk of adverse effects associated with Percocet, as noted by the DON and Pharmacist Consultant. The facility's records and interviews consistently indicated that the error was due to the nurse mistakenly selecting the incorrect medication from the E-kit.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to treat three residents with dignity and respect during a lunch service. Residents 21, 22, and 29, who required full assistance with meals, were not offered or fed their bread rolls. During a dining observation, RN 3 asked Resident 29 if she wanted her bread roll, to which she replied affirmatively. However, RN 3 did not have gloves available to feed the bread roll and instead offered water to Resident 29. Consequently, Residents 21, 22, and 29 did not receive their bread rolls from the staff assisting them. In an interview, the Director of Staff Development acknowledged that RN 3 should have accommodated Resident 29's request for the bread roll. The facility's policy on dignity, revised in February 2021, emphasizes that each resident should be cared for in a manner that promotes their well-being and self-esteem, including providing a dignified dining experience. The failure to assist these residents with their bread rolls potentially affected their psychosocial well-being and nutritional needs.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic drugs, affecting three residents. Resident 8 was prescribed Seroquel, an antipsychotic medication, without appropriate indications. The resident had a diagnosis of brief psychotic disorder but was not exhibiting aggressive behavior or posing a danger to themselves or others, as confirmed by interviews with a CNA and an RN. The Director of Nursing acknowledged that the use of Seroquel was not appropriate for Resident 8. Resident 7 was prescribed Ativan, a psychotropic medication, on a PRN basis for anxiety without a stop date, contrary to the facility's policy that limits PRN orders to 14 days unless extended with documented rationale. The Director of Nursing and the Medical Doctor confirmed that the PRN Ativan should have had a stop date, and there was no documentation to justify its continued use beyond 14 days. Resident 10 was administered Trazadone for insomnia, but the facility failed to monitor the resident's hours of sleep, which is necessary to evaluate the medication's effectiveness. The Director of Nursing admitted that monitoring was not conducted, which is essential to determine if the medication is working and if the physician needs to be notified for reevaluation. The facility's policy requires adequate monitoring for efficacy and adverse consequences of psychotropic medications.
Failure to Follow Dietary Menu for Residents
Penalty
Summary
The facility failed to adhere to the established menu for residents on soft and bite-sized and easy to chew diets, affecting 12 residents. During a tray line observation, it was noted that the Dietary Services Supervisor (DSS) did not serve the required two ounces of gravy with the baked chicken for these residents. This omission was confirmed during a record review of the facility's Therapeutic Spreadsheet Menu, which specified that the gravy was part of the meal for these dietary requirements. In an interview, the DSS admitted to preparing the gravy but forgetting to serve it, acknowledging that the weekly menu should have been followed. The facility's policy and procedure document, dated 2018, mandates that menus are planned to meet federal and state guidelines and provide adequate nutrients for residents' special needs, including dietary modifications. The failure to serve the gravy as per the menu had the potential to impact the residents' ability to chew and swallow their food properly.
Sanitation and Hygiene Deficiencies in Food Preparation
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, as observed during a survey. The can opener used in the kitchen had red discoloration on the blade, indicating it was not cleaned properly after use. The Dietary Service Supervisor (DSS) acknowledged that the can opener should have been cleaned. Additionally, the kitchen floors under the stoves and steam table tray line were found to have a build-up of food crumbs, dust, trash, and grime, which the DSS attributed to a lack of deep cleaning following the retirement of the staff member responsible for this task. The oven also had a build-up of black grime, which was identified as food residue, and the Registered Dietician (RD) confirmed that the oven should have been cleaned according to the cleaning schedule. Further observations revealed that the dry storage area had floors with food crumbs, trash, and dead ants, which were not cleaned promptly. The RD stated that the kitchen should have been kept clean and free from such debris. Additionally, a Diet Aide (DA) with facial hair was observed not wearing a beard net during meal preparation and service, contrary to the facility's policy on personal hygiene. The facility's policies and procedures, as well as the FDA Federal Food Code, emphasize the importance of maintaining cleanliness to prevent cross-contamination and foodborne illnesses, which were not adhered to in this instance.
Failure to Conduct PASARR Evaluation for Resident with Psychotic Disorder
Penalty
Summary
The facility failed to ensure that Resident 8 underwent a Preadmission Screening and Resident Review (PASARR), which is a federal requirement for evaluating individuals with mental disorders or intellectual disabilities before admission to a Medicaid-certified nursing facility. Resident 8, who was diagnosed with a brief psychotic disorder, was admitted without this necessary evaluation. The absence of a PASARR evaluation meant that it was not determined whether Resident 8 was receiving appropriate mental health services or if the nursing facility was the most suitable setting for their needs. The deficiency was identified during a review of Resident 8's admission records and physician's orders, which included a prescription for Seroquel, an antipsychotic medication. The Medical Record Director confirmed the lack of a PASARR evaluation in the resident's medical records. The facility's Administrator acknowledged the oversight, admitting that it was a mistake on the facility's part. The facility's policy, dated March 2019, mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders as per PASARR requirements.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. For Resident 10, the facility did not create a care plan to address the resident's diagnoses of Major Depressive Disorder and Insomnia, nor did it include the use of prescribed medications Amitriptyline and Trazadone in the care plan. During a review, the Director of Nursing (DON) confirmed the absence of a care plan for these conditions and medications, indicating a lack of documentation and initiation of necessary care planning. Similarly, the facility did not identify or address a hairy mole on Resident 11's chin in the care plan. Despite the resident expressing a desire for the hair to be removed and the presence of the mole being acknowledged by a Certified Nursing Assistant (CNA), there was no documentation or care plan addressing this issue. The DON confirmed that the nursing staff failed to identify or care plan for the mole, which was contrary to the facility's policy requiring comprehensive, person-centered care plans to be developed within seven days of the MDS assessment.
Failure to Provide Podiatry Care
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 14, received necessary podiatry care for long toenails as ordered by the physician. During an observation, it was noted that Resident 14, who was bedridden and had contracted feet, had long toenails. The resident's Minimum Data Set (MDS) indicated that she had both short- and long-term memory problems, was dependent on staff for personal hygiene, and had diagnoses including Peripheral Artery Disease and Non-Alzheimer's Dementia. Despite these conditions, the resident's toenails were not trimmed as per the podiatrist's plan to provide foot care every 2 to 3 months. Further investigation revealed that the Social Services Director acknowledged that Resident 14's foot care was missed and that the resident had not been seen by the podiatrist as scheduled. The facility's policy on foot care, revised in October 2022, stated that residents with foot disorders or medical conditions associated with foot complications should be referred to qualified professionals. However, the resident's order summary report indicated that podiatry care was to be provided as needed, which was not adhered to, leading to the deficiency.
Failure to Provide Splint for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate treatment services for a resident with a contracture in the right upper extremity. The resident, who had a diagnosis of Non-Alzheimer's Dementia and memory problems, was observed without a resting splint on the right hand, despite a physician's order for its application. The resident's care plan included a nursing rehab/restorative splint/brace program, and the physician had prescribed a restorative nurse assistant program to perform passive range of motion exercises to maintain joint range of motion and reduce the risk of contracture development. Interviews with staff, including a CNA, LVN, and OT, revealed that the resident had not been on the restorative program for some time and had not used a splint recently. The CNA and LVN, who were responsible for the resident's care, were unaware of the current status of the splint application. The OT confirmed that there was no treatment record for the resident's right hand limitation in range of motion. The facility's policy indicated that residents should be provided with care to maintain or improve their ability to carry out activities of daily living, which was not adhered to in this case.
Lack of Contract with Dialysis Provider
Penalty
Summary
The facility failed to establish a written contract or agreement with the outpatient dialysis provider responsible for a resident's dialysis care. This deficiency was identified during a review of the resident's records and interviews. The resident, who was diagnosed with acute kidney failure, required outpatient hemodialysis sessions twice a week. Despite the resident's intact cognition and regular dialysis appointments, the facility administrator admitted there was no contract in place with either the dialysis provider or the transportation company used for the resident's dialysis appointments. The administrator acknowledged awareness of the regulatory requirement for such contracts but had not yet implemented them.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within easy reach for two residents, leading to a deficiency in care. During an initial tour, it was observed that Resident 15's call button wire was hanging on the right middle side of the bed, almost touching the floor, making it difficult for the resident to reach. Resident 15, who was alert and able to answer questions, attempted to reach the call button but was unsuccessful. A Certified Nursing Assistant (CNA) confirmed that the call light was not within reach and acknowledged the risk of unmet needs due to this inaccessibility. Similarly, Resident 21 was found with the call light on the floor, out of reach, during the same tour. The Licensed Vocational Nurse (LVN) confirmed that the call light should not be on the floor and should always be accessible to the resident. The Director of Nursing (DON) stated that residents should always be able to reach their call lights, especially when in bed, to prevent unmet needs. The facility's policy and procedure on answering call lights, dated September 2022, indicated that call lights should be accessible from the bed, toilet, shower, or bathing facility.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Berkeley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kyakameena Care Center | 1.2 mi | ★★★★★ | 26 | 0 |
| Elmwood Care Center | 1.3 mi | ★★★★★ | 7 | 0 |
| Ashby Care Center | 1.4 mi | ★★★★★ | 3 | 0 |
| Berkeley Pines Skilled Nursing Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Shields Nursing Center | 2.5 mi | ★★★★★ | 3 | 0 |
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