Chestnut Ridge Post Acute Llc
CHESTNUT RIDGE POST ACUTE LLC in GLENDALE, CA — inspection on March 31, 2026.
Found 2 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 a review of Resident 1's Care Plan Resident has potential for injury, worsening in condition related to non-compliance as evidence by refusing to reinsert foley catheter dated 12/9/2025, the Care Plan did not include any wound protective measures or moisture preventive interventions.
During a concurrent interview and a record review on 3/27/2026 at 3 PM with the Treatment Nurse (TXN), Resident 1's clinical records were reviewed. TXN stated since 11/25/2025 Resident 1 refused reinsertion of foley catheter the resident did not have a foley catheter prior to discharge. TXN stated she was not sure how often Resident 1 was turned/repositioned by staff. TXN stated she was not sure how frequent staff checked or changed Resident 1's incontinence brief. TXN stated that the facility did not develop or indicate on the Care Plan to ensure that Resident 1 was turned or repositioned at least every two hours. TXN also stated that the Care Plan regarding Resident 1 refusal of a foley catheter did not have effective measures to protect Resident 1's sacrococcyx PI.
During an interview on 3/27/25 at 4PM with the Director of Nursing (DON), the DON stated that the staff were supposed to ensure that Resident 1 was turned at least every two hours and that Resident 1's wound dressing was protected from soiling by incontinence.
The DON stated preventative measures like repositioning and moisture reduction were very important for Resident 1 to lower the risks for PI wound infection and deterioration, however IDT did not address this risk, therefore the Care Plan was not revised.
During a review of the facility's Policy and Procedures (P&P) Prevention of Pressure Injuries reviewed in 6/2025, the P&P indicated the following: Keep the skin clean and hydrated,Clean promptly after episodes of incontinence,Use a barrier product to protect skin from moisture,Reposition all residents with or at risk of pressure injuries on an individualized schedule, Teach residents who can change positions independently the importance of repositioning.
Provide support devices and assistance as needed.
Remind and encourage residents to change positions.Review the interventions and strategies for effectiveness on an ongoing basis.
056190 03/31/2026
Chestnut Ridge Post Acute LLC 525 South Central Avenue Glendale, CA 91204
During a concurrent interview and
between 4 AM and 4:30 AM. MDSN stated Resident 1's IDTCR should have been completed and
interventions for fall precautions should have included frequent monitoring even though there was a bed alarm to alert the staff about resident's movement in bed. MDSN stated that finding the causes of a resident's fall was important because it was the first step to develop a resident-centered care plan and apply appropriate interventions tailored to Resident 1's specific needs.
During an interview on 3/31/2026 at 2:45 PM with the Director of Nursing (DON), the DON stated that Resident 1 had Parkinson's Disease and was cognitively impaired.
The DON stated Resident 1 did not have a care plan for supervision after Resident 1 sustained her first fall on 11/11/2025.
The DON stated she was not sure why floor mat was recommended by the IDT but never ordered or applied to Resident 1.
The DON also stated the staff failed to try to identify and document specific factors and causes of resident's fall and failed to implement a resident-centered Care Plan interventions.
The DON stated since the cause of the fall was not identified and specific needs were not implemented for Resident 1, the DON stated Resident 1 could likely sustain another fall.
During a review of the facility's policy and procedures (P&P) Assessing Falls and Their Causes reviewed in 6/2025, the P&P indicated the following: Within 24 hours of a fall, try to identify possible or likely causes of the incident, Evaluate chains of event or circumstance preceding a recent fall, Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found,Consult with the attending physician or medical director to confirm specific causes from among multiple possibilities.
During a review of the facility's policy and procedures (P&P) Care Plans, Comprehensive Person-Centered reviewed in 6/2025, the P&P indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.
The P&P also indicated that assessment of residents are ongoing and care plans are revised as information about the residents and residents' condition change.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENDALE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CHESTNUT RIDGE POST ACUTE LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.