F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure that a comprehensive, person-centered care plan
was developed for one of two sampled resident (Resident 1) who was assessed to be at risk of elopement
(the act of leaving a facility unsupervised and without prior authorization) and wandering.
This deficient practice had the potential for Resident 1 to not receive care that would prevent the resident
from wandering into other resident ' s rooms, which could be a violation of other resident ' s privacy and
rights, and/or elope from the facility.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated the resident was admitted on
[DATE] with diagnoses that included Alzheimer ' s disease (a disease characterized by a progressive
decline in mental abilities) and dementia (a progressive state of decline in mental abilities), and cognitive
communication disease.
During a review of Resident 1 ' s History and Physical (H&P), dated 4/25/2025, the H&Pindicated the
resident does not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated
4/25/2025, the MDSindicated the resident has severe impaired cognition (the ability to process thoughts).
The MDS also indicated the resident requires moderate assistance (helper does less than half the effort) on
activities such as walking up to 50 feet and sitting to standing. The MDS also indicated the resident requires
substantial assistance (helper does more than half the effort) for self-care activities such as putting
on/taking off footwear, toileting, and personal hygiene.
During a review of Resident 1 ' s Elopement Evaluation (EE), dated 4/21/2025, the EE indicated Resident 1
wandered aimlessly or non-goal-directed. The EE indicated the resident was at risk for wandering or
elopement.
During a review of Resident 1 ' s active care plans, there were no care plans for Resident 1 initiated to
address Resident 1 ' s behavior of wandering or elopement.
During an interview on 5/28/2025 at 12:39 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1
wandered around the facility and was at risk for elopement. RN 1 stated Resident 1 could walk by himself
and wandered around the facility.
(continued on next page)
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:
056190
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
056190
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/28/2025
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a concurrent interview and record review on 5/28/2025 at 2:32 PM with Director of Nursing (DON),
Resident 1 ' s active care plans and EE, dated 4/21/2025, were reviewed. DON stated Resident 1 did not
have a care plan that addressed Resident 1 ' s behaviors of wandering and for being at risk for elopement.
DON stated there should be a care plan for the resident ' s behavior since the care plan wasused to inform
all staff on which specific interventions to implement for Resident 1. DON stated the care plan for the
resident ' s behavior of wandering and risk of elopement should include interventions such as close
monitoring or moving the resident to a room closer to the nurses ' station.
During a record review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive
Person-Centered, revised 3/2022, indicated the care plan interventions address the underlying source(s) of
the problem area(s), not just symptoms or triggers. The P&P also indicated the comprehensive,
person-centered care plan:
1. Includes measurable objectives and timeframes;
2. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable,
mental, and psychosocial well-being, including:
a. services that would otherwise be provided for the above, but are not provided due to the resident
exercising his or her rights, including to refuse treatment;
3. builds on the resident ' s strengths; and
4. reflects currently recognized standards of practice for problem areas and conditions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056190
If continuation sheet
Page 2 of 2
