Chestnut Ridge Post Acute Llc

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

to a different facility prior to the most recent admission. SW 1 stated Resident 3's POLST was found in Resident 3's previous medical records and not placed in Resident 3's current medical chart. During a concurrent interview and record review on [DATE REDACTED] at 3:35 PM with SW 1, Resident 4's records were reviewed. There was not POLST for Resident 4 found. SW 1 stated she did not know if Resident 4 has a POLST. During another concurrent interview and record review on [DATE REDACTED] at 3:35 PM with SW 1, Resident 5's records were reviewed. Resident 5's POLST could not be found. SW 1 stated Resident 5's POLST might be in the resident's old records. During another concurrent interview and record review on [DATE REDACTED] at 3:35 PM with SW 1, Resident 6's records were reviewed. Resident 6's POLST could not be found. SW 1 stated that she is not sure if Resident 6 had a POLST. During another concurrent interview and record review on [DATE REDACTED] at 3:35 PM with SW 1, Resident 7's records were reviewed. SW 1 could not locate Resident 7's POLST and stated that Resident 7 was able to make decisions. During another concurrent interview and

record review on [DATE REDACTED] at 3:35 PM with SW 1, Resident 8's records were reviewed. SW 1 stated that Resident 8 was new to the facility and did not know if Resident 8 had a POLST. SW 1 stated that it was SW 1's responsibility to obtain the POLST for newly admitted residents. During another concurrent interview and record review on [DATE REDACTED] at 3:35 PM with SW 1, Resident 9's records were reviewed. SW 1 stated that Resident 9 was new to the facility. Resident 9's POLST was not found in Resident 9's current medical chart.

SW 1 stated she was unsure if Resident 9 was offered a POLST. During another concurrent interview and

record review on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Ridge Post Acute LLC

525 South Central Avenue Glendale, CA 91204

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 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

necessary for CPR/BLS in the facility at all times.? 5. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac?arrest is likely, begin CPR.? 6. The BLS sequence of events is?referred to as C-A-B (chest compressions, airway, breathing).? 7. Chest compressions:? Following initial assessment, begin CPR with chest compressions;? Push hard to a depth of at least 2 inches (5?cm [centimeters, a unit of measuring length]) at a rate of at least 100 compressions per minute;? Allow full chest recoil after each?compressions; and? Minimize interruptions in chest compressions.? Airway: Tilt head back and lift chin to clear airway.? Breathing: After 30 chest compressions provide 2 breaths via?Ambu-bag or manually (with CPR shield).? 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.? Continue with CPR/BLS until emergency medical personnel arrive.? ?

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Ridge Post Acute LLC

525 South Central Avenue Glendale, CA 91204

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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED] 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 REDACTED] at 3:15 PM with CNA 3, CNA 3 stated that she was hired by the facility in [DATE REDACTED].

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 REDACTED] 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 REDACTED], CNA 3 has[TRUNCATED]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Ridge Post Acute LLC

525 South Central Avenue Glendale, CA 91204

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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

at 3:45 PM, MD 2 stated if the facility's staff could not get ahold of a resident's primary MD regarding abnormal lab/diagnostic results or change in condition, they were directed to call the medical director.

During a concurrent interview and record review with the Director of Nursing (DON) on [DATE REDACTED] at 5:57 PM, Resident 1's MAR for September to [DATE REDACTED] was reviewed. The DON stated she could not find documented evidence that the Acetylcysteine, Budenoside, and Ipratropium-Albuterol respiratory medications were administered Resident 1. The DON further stated that by not receiving the respiratory medications as ordered, Resident 1 was placed at risk of COPD exacerbation (a sudden worsening of breathing symptoms, such as increased shortness of breath, cough, or sputum), which could lead to hospitalization or death.

During another interview with MD 1 on [DATE REDACTED] at 2:30 PM, MD 1 stated that NP 1 ordered CPT with Acetylcysteine to help with Resident 1's worsening chest congestion while waiting for the lab and chest x-ray results. MD 1 further stated that if she was made aware of Resident 1's abnormal chest x-ray with left lung opacity and elevated WBC of 16.85 x10*3/ul, she would have ordered antibiotics for Resident 1. MD 1 stated that Resident 1 could have become septic if the infection was left untreated. During the same

interview with MD 1, MD 1 stated that Acetylcystiene, Budenoside, and Ipratropium-Albuterol respiratory medications were ordered specifically to help with Resident 1's COPD and missing several doses, especially consecutively, could trigger Resident 1 to experience a COPD exacerbation, further explaining that this could have led to Resident 1 experiencing a medical emergency from COPD exacerbation. 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. 4. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 5. The nurse will record in the resident' s medical record information relative to changes in the resident's medical/mental condition or status. 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 REDACTED], the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Ridge Post Acute LLC

525 South Central Avenue Glendale, CA 91204

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

record review with the Director of Nursing (DON) on 1/2/2026 at 5:57 PM, Resident 1's MAR for September to December 2026 was reviewed. The DON stated she could not find documented evidence that the Acetylcysteine, Budenoside, and Ipratropium-Albuterol respiratory medications were administered Resident

1. 1. The DON further stated that by not receiving the respiratory medications as ordered, Resident 1 was

placed at risk of COPD exacerbation (a sudden worsening of breathing symptoms, such as increased shortness of breath, cough, or sputum), which could lead to hospitalization or death. During an interview with MD 1 on 1/5/2026 at 2:30 PM, MD 1 stated that Acetylcystiene, Budenoside, and Ipratropium-Albuterol respiratory medications were ordered specifically to help with Resident 1's COPD and missing several doses, especially consecutively, could trigger Resident 1 to experience a COPD exacerbation, further explaining that this could have led to Resident 1 experiencing a medical emergency from COPD exacerbation. During a review of the facility policy and procedure (P&P) titled Administering Medications dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Ridge Post Acute LLC

525 South Central Avenue Glendale, CA 91204

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 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

in status. During an interview with MD 2 on [DATE REDACTED] at 3:45 PM, MD 2 stated if the facility's staff cannot get a hold of a resident's primary MD regarding abnormal lab/diagnostic results or change in condition, they were informed to call the medical director. During another interview with MD 1 on [DATE REDACTED] at 2:30 PM, MD 1 stated that NP 1 ordered CPT with Acetylcysteine to help with Resident 1's new chest congestion while waiting for the lab and chest x-ray results. MD 1 further stated that if she was made aware of Resident 1's chest x-ray with left lung opacity and WBC 16.85 x10*3/ul, she would have ordered antibiotics for the resident. MD 1 stated that Resident 1 could have become septic if the infection was left untreated. During a

review of the facility's Policy and Procedure (P&P) titled Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE REDACTED], the P&P indicated the following: 1. When test results are reported to the facility, a nurse will first review the results 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the individual's current condition and details of any recent changes in status such as major diagnoses and any recent pertinent lab work. 3. A nurse will identify the urgency of communicating with the Attending Physician, the seriousness of any abnormality, and the individual's current condition. 4. Nursing staff will consider whether

the resident's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving to identify situations requiring prompt physician notification concerning lab or diagnostic test results. 5. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record. b.

Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs

review or clarification. 6. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON and/or Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Ridge Post Acute LLC

525 South Central Avenue Glendale, CA 91204

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

medications Resident 1 received. LVN 9 stated she could only remember that Resident 1 received Albuterol breathing treatments, but stated she could not remember if the resident also received Budenoside or Acetylcysteine. LVN 9 also stated she could not recall what time she gave Resident 1's medications on 12/4/2025 or if any of the resident's medications were withheld for the month of December 2025. LVN 9 further stated that she was responsible for administering medications to many residents and therefore could not remember what medications she gave in the past, specifically for December 2025, or what time she administered them to Resident 1. During the same interview with LVN 9 on 1/2/2026 at 5:18 PM, LVN 9 stated the reason she documented Resident 1's acetylcysteine, budenoside, and ipratropium-albuterol administrations on 12/30/2025 and 1/1/2026 was because Medical Records Assistant (MRA) 1 audited Resident 1's MAR and discovered missing administration documentation. LVN 9 stated that when Medical Records notified her of the missing administration documentation, she then documented that she administered the medications in order to complete the audit. LVN 9 explained that this was her usual practice of completing medical record audits for medication administrations. LVN 9 further stated she knew

she was supposed to document medication administrations immediately after administering the medication, but stated she forgot about it until MRA 1 audited her documentation. 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.

Event ID:

Facility ID:

If continuation sheet