Chestnut Ridge Post Acute Llc
CHESTNUT RIDGE POST ACUTE LLC in GLENDALE, CA — inspection on January 2, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 10's records were reviewed. Resident 10's POLST was not found in Resident 10's current medical chart.
During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 11's records were reviewed. SW 1 stated Resident 11's POLST and AD were not in Resident 11's current medical chart. SW 1 stated that the POLST should be in the resident's chart and not in her office.
During another concurrent interview record review on [DATE] at 3:56 PM with SW 1, the facility's policy and procedures (P&P) titled, Advance Directives, dated 9/2022, was reviewed. SW 1 stated that the P&P indicated that upon admission, the social workers must inquire about the resident's POLST or AD. SW 1 stated that the term upon admission means within 48 to 72 hours upon the resident's admission. SW 1 stated that the P&P indicated that if the resident has an AD or a POLST, the documents must be in the resident's medical records and is accessible to any facility staff, and not in her office.
During an interview on [DATE] at 11:41 AM with the DON, the DON stated that it is the responsibility of SW 1 to obtain the residents' AD and POLST within 48 hours of admission to the facility.
The DON stated that if there was a POLST, the POLST must be in the resident's current medical chart.
The DON stated that facility staff use the POLST to identify if residents are full code, especially in an emergency such as when a resident is found unresponsive.
During a review of the facility Job Description (JD) for a social worker titled, Social Services Designee, undated, the JD indicated that the SW works with residents to complete advance directive documentation.
During a record review of the facility's P&P titled, Advance Directive, dated 9/2022, the P&P indicated that if the resident or representative has not established an advance directive for the resident, the facility staff will offer assistance in establishing advance directive.
The P&P also indicated that information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section that is retrievable by any staff.
The P&P also indicated that if the resident has an advance directive, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.
056190 01/02/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches. 5.
For adults in cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 [per minute]. 6. It is reasonable for lay rescuers and health care professionals to perform CPR with cycles of 30 compressions followed by 2 breaths before placement of an advanced airway. 7.
Bag-mask ventilation is most effective when provided by 2 trained and experienced rescuers; 1 rescuer opens the airway and seals the mask to the face with both hands while the other rescuer (who might also be the chest compressor) squeezes the bag during the pauses in chest compression.
During a review of the facility'sˆP&P titled,ˆ Emergency Procedure- Cardiopulmonary Resuscitation,ˆdated 2/2018,ˆthe P&Pˆindicatedˆthatˆthe following:ˆ 1.Theˆchances of a resident surviving a cardiac arrest may be increased if CPR is initiated immediately.ˆ 2. If a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR.ˆ 3.
The facility's procedure for administering CPR shall incorporate the steps covered in the 2010ˆAmerican Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material.ˆ
- Maintain equipment and supplies necessary for CPR/BLS in the facility at all times.ˆ 5. If an
individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiacˆarrest is likely, begin CPR.ˆ 6.
The BLS sequence of events isˆreferred to as C-A-B (chest compressions, airway, breathing).ˆ 7.
Chest compressions:ˆ Following initial assessment, begin CPR with chest compressions;ˆ Push hard to a depth of at least 2 inches (5ˆcm [centimeters, a unit of measuring length]) at a rate of at least 100 compressions per minute;ˆ Allow full chest recoil after eachˆcompressions; andˆ Minimize interruptions in chest compressions.ˆ Airway: Tilt head back and lift chin to clear airway.ˆ Breathing: After 30 chest compressions provide 2 breaths viaˆAmbu-bag or manually (with CPR shield).ˆ All rescuers, trained or note, should provide chest compressions to victims of cardiac arrest.
Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.ˆ Continue with CPR/BLS until emergency medical personnel arrive.ˆ ˆ
056190 01/02/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
During an interview on [DATE] at 10:45 AM with safety LVN 4, LVN 4 stated that on [DATE], she was in Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive. LVN 4 stated that she brought the EC into Resident 1's room. LVN 4
at 11:08 AM with RN 5, RN 5 stated that if a resident is found unresponsive and pulseless, she would initially check the resident's code status. RN 5 then stated that after confirming that the resident is full code, the emergency cart will be brought inside the resident's room and CPR will be initiated.
During an interview on [DATE] at 11:47 AM with LVN 7, LVN 7 stated that if a resident is found unresponsive and pulseless, she would check the resident's code status first. LVN 7 stated that if the resident is full code, she will start CPR. LVN 7 stated that the rate of compression during a CPR is 30 compressions per minute.
During a concurrent interview and record review on [DATE] at 2:00 PM with the DSD, the entire facility's direct care employee records were reviewed, including each staff member's BLS/CPR certification.
The DSD stated that CNA 3 and LVN 2 do not have a BLS/CPR certification on file.
The DSD stated that she was aware that CNA 3 and LVN 2 have not submitted their BLS/CPR certification
During an interview on [DATE] at 3:07 PM with the DON, the DON stated that when a staff member finds that a resident is unresponsive, the staff member should check the resident's vital signs (are measurements of the body's most basic functions-temperature, pulse rate, respiration rate, and blood pressure), such as the pulse, blood pressure, and respirations.
The DON stated that if the resident was found to be pulseless, not breathing, and unresponsive, the staff member should initiate Code Blue by shouting Code Blue to alert other staff members into the room then initiate CPR right away.
The DON added that when CPR has been initiated, other staff members may call for 911 and verify the resident's code status.
During the same interview on [DATE] at 3:07 PM with the DON, the DON stated that in order to deliver quality CPR, staff members must use a backboard and the Ambu-bag.
The DON stated that the backboard is placed under the resident when performing CPR.
The DON added that an Ambu-bag is used to provide the resident two rescue breaths after 30 compressions.
The DON also added that CPR must be performed at a rate of 100 to 120 compressions per minute.
During an interview on [DATE] at 3:15 PM with CNA 3, CNA 3 stated that she was hired by the facility in [DATE]. CNA 3 stated that she has not provided a copy of her CPR Certificate to the facility. CNA 3 stated that if she finds a resident who is unresponsive, she will put the resident's chin up and perform CPR at the rate of 15 compressions per minute.
During an interview on [DATE] at 4:05 PM with the DSD, the DSD stated that it is her responsibility to ensure that all the facility's nursing staff have updated and non-expired licenses and certifications.
The DSD confirmed that since [DATE], CNA 3 has[TRUNCATED]
056190 01/02/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
During a review of the facility's P&P titled Resident Examination and Assessment, the P&P indicated the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan.
The P&P further indicated how to perform a full head-to-toe assessment and indicated to notify the physician of any abnormalities such as labored breathing; breath sounds that are not clear; or cough, productive or nonproductive.
During a review of the facility policy and procedure (P&P) titled Administering Medications dated [DATE], the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe.
056190 01/02/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
During a review of the American Red Cross skill sheet CPR for Adults, dated 2019, the skill sheet indicated to compress the chest at a depth of at least 2 inches and to provide smooth compressions at a rate of 100 to 120 per minute.
056190 01/02/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
interview with MD 1 on 1/5/2026 at 2:30 PM, MD 1 stated that Acetylcystiene, Budenoside, and
COPD exacerbation, further explaining that this could have led to Resident 1 experiencing a medical
Administering Medications dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe.
056190 01/02/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
During a review of the facility's P&P titled Change in a Resident's Condition or Status, revised February 20121, the P&P indicated the following: 1.
The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions 3.
Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status.
056190 01/02/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
During an interview with the Director of Nursing (DON) on 1/2/2026 at 5:57 PM, the DON stated that LVN 3 and LVN 9 should have documented Resident 1's medication administrations in a timely manner. If there were issues with the MAR, they were required to document why medications were documented at a later time in Resident 1's progress notes.
The DON stated that physicians and nurses use documentation to monitor effectiveness and adverse reactions to medications, and if the records were inaccurate, providers may delay adjusting medications or initiating new treatments.
During a phone interview with MRA 1 on 1/13/2026 at 1:51 PM, MRA 1 stated he did MAR audits every day with a lookback period of up to 30 days. MRA 1 stated that the audit specifically searched for missing documentation in a resident's MAR.
After finding missing documentation, MRA 1 stated he submitted the audit report to the DON and the DON would tell the licensed nurses to complete the documentation. MRA 1 stated that the audit would be considered resolved if the nurse documented that the medication was administered or a reason the medication was not administered.
During a review of the facility's policy and procedure (P&P) titled Administering Medications revised April 2019, the P&P indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.