Health inspection·July 9, 2025

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behavioral condition, including schizophrenia and bipolar disorder) 10 milligram (MG, a unit of measurement) one tablet by mouth two times a day for bipolar manifested by striking out at staff, starting on 5/27/2025. 2.Valproic Acid (a medicine used to treat bipolar disorder) 250 MG three capsules by mouth as two times a day for bipolar disorder manifested by inconsolable screaming, starting on 5/27/2025. 3.Venlafaxine (a medicine used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [a common emotion characterized by feelings of unease, worry, or fear, which can range from mild to severe])5 MG one tablet by mouth two times a day for restlessness, starting on 5/27/2025. During a review of Resident 1's Medication Administration Record (MAR), dated 5/2025, the MAR indicated Resident 1 refused to take Haloperidol 10 MG one tablet on 5/27/2025 at 6 PM, 5/28/2025 at 9 AM at 6 PM, 5/29/2025 at 9 AM and 6 PM, 5/30/2025 at 9 AM. The MAR also indicated Resident 1 refused to take Valproic Acid 250 MG three capsules on 5/28/2025 9 AM and 5/29/2025 9 AM. During a review Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Haloperidol 10 MG one tablet on: a. 6/1/2025 at 9 AM and 6 PM b. 6/2/2025 at 9 AM and 6 PM c. 6/3/2025 at 9 AM and 6 PM d. 6/4/2025 at 9 AM e. 6/5/2025 at 9 AM and 6 PM f. 6/6/2025 at 9 AM and 6 PM g. 6/7/2025 at 9 AM h. 6/8/2025 at 9 AM and 6 PM i. 6/10/2025 at 9 AM and 6 PM j. 6/11/2025 at 9 AM and 6 PM k. 6/12/2025 at 6 PM l. 6/13/2025 at 9 AM and 6 PM m. 6/14/2025 at 9 AM n. 6/15/2025 at 9 AM and 6 PM o. 6/16/2025 at 9 AM p. 6/17/2025 at 6 PM q. 6/19/2025 at 6 PM r. 6/20/2025 at 9 AM and 6 PM During a review of Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Valproic Acid 250 MG three capsules on: a. 6/3/2025 at 9 AM b. 6/6/2025 at 6 PM c. 6/12/2025 at 6 PM d. 6/13/2025 at 9 AM and 6 PM e. 6/14/2025 at 9 AM f. 6/15/2025 at 9 AM and 6 PM g. 6/17/2025 at 6 PM h. 6/19/2025 at 6 PM i. 6/20/2025 at 9 AM and 6 PM The MAR indicated Resident 1 received only a partial administration of Valproic Acid 250 MG three capsules on 6/8/2025 at 6 PM, 6/9/2025 at 6 PM, 6/10/2025 at 6 PM and 6/11/2025 at 6 PM. The MAR indicated Resident 1 did not receive the entire dose of Valproic Acid 250 MG three capsules on 6/5/2025 at 6 PM and was only administered one tablet. During a review of Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Venlafaxine 75 MG one tablet on 6/6/2025 at 6 PM. During a review of Resident 1's Progress Notes (PN), dated 6/8/2025 at 5:34 PM, the PN indicated Resident only took one capsule of Valproic Acid 250 MG. During a review of Resident 1's Change in Condition Evaluation (COC), dated 6/12/2025 at 10:22 AM, the COC indicated Registered Nurse (RN) 1 reported to the physician that Resident 1 was non complaint with medication administration since Resident 1 kept refusing to take the medication, valproic acid. During a review of Resident 1's PN, dated 6/12/2025 at 10:22 AM, the PN indicated RN 1 reported to the physician that Resident 1 kept on refusing medications but there was no documentation for recommendations, new testing orders and new intervention ordered by the physician. During a review of Resident 1's PN, dated 6/20/2025 at 3:14 PM, the PN indicated that at 12:25 PM, Resident 1 allegedly approached Resident 2 in the smoking patio and asked Resident 2 for a cigarette, but Resident 2 stated he did not have a cigarette, so Resident 1 pushed Resident 2 and continued a verbal altercation. During a review of Resident 1's PN, dated 6/20/2025 at 8:04 PM, the PN indicated that the facility called 911 and transferred Resident 1 to the General Acute Care Hospital (GACH) at 7:10 PM for 5150. During an interview on 7/9/2025 at 11:25 AM with Restorative Nursing Assistant (RNA) 1, RNA 1, RNA 1 stated on 6/20/2025 after lunch, he was doing something in the hallway and he heard Resident 1 and Resident 2 arguing in the smoking patio, then, he tried to separate the residents. RNA 1 stated Resident 2 said Resident 1 was asking for a cigarette from him, but Resident 2 said he did not have a cigarette, then, Resident 1 pushed Resident 2. During an interview on 7/9/2025 at 12:17 PM with RN 2, RN 2 stated Resident 1 would become verbally aggressively toward staff when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 2 of 4 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 07/09/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff did not attend to his request immediately. RN 2 stated the charge nurses reported that Resident 1 would refuse to take medications, then, the nurse would educate the resident about the risk of refusing medication, informed the responsible party (RP) to convince the resident, and notify the physician. RN 2 stated she did not know how often and how many medications Resident 1 had refused since his admission, and she did not know if any interventions were developed and implemented to address Resident 1's behavior of refusing medications frequently. During an interview on 7/9/2025 at 1:40 PM with Licensed Vocational Nursing (LVN) 2, LVN 2 stated Resident 1 had refused his medication since the first day he was admitted into the facility. LVN 2 stated Resident 1's refusal of medications increased before Resident 1 was transferred to the GACH. LVN 2 stated she reported Resident 1's refusal of medication to the RN supervisor and the RN supervisor was responsible for assessing Resident 1 and reporting to and following up with the physician. During a telephone interview on 7/9/2025 at 3:50 PM with RN 1, RN 1 stated on 6/12/2025, the charged nurse informed her that Resident 1 refused to take medications, such as metformin, haloperidol and valproic acid, so RN 1completed the COC, and reported Resident 1's refusals of medications to the nurse practitioner (NP) of Resident 1's psychiatrist. RN 1 stated the NP stated she would come to the facility and visit with Resident 1, however RN 1 did not document NP's response or COC onto Resident 1's medical record. RN 1 stated she did not know if the NP or the psychiatrist came to see Resident 1 after informing NP of Resident 1 refusing medications. RN 1 stated she had not followed up with Resident 1's COC nor did RN 1 know if Resident 1's refusal of meds was followed up. RN 1 stated she did not know Resident 1 refused the prescribed medication haloperidol almost every day and RN 1 did not know how often Resident 1 refused another prescribed medication valproic Acid. During an interview on 7/9/2025 at 4:01 PM with LVN 3, LVN 3 stated Resident 1 often refused medications, and she remembered she called Resident 1's primary physician about it Resident 1's refusal of medications, however did not inform Resident 1's psychiatrist since Resident 1's primary provided stated they would reach out to the psychiatrist. LVN 3 could not state whether Resident 1's psychiatrist knew Resident 1 refused the prescribed psychotropic medications or if Resident 1 had been reevaluated by the psychiatrist. LVN 3 stated it was not her responsibility to follow up with the physician for further orders, instead, it was the RN supervisors' responsibility to do that. LVN 3 stated she did not know if the RN supervisors follow up with it. During a concurrent interview and record review on 7/9/2025 at 4:20 PM with the Director of Nursing (DON), Resident 1's MAR, dated 5/2025 and 6/2025 were reviewed. The DON stated Resident 1, who had the diagnosis of schizophrenia and bipolar disorder, exhibited behaviors of refusing the prescribed psychotropic medications, which was a COC for Resident 1. The DON stated she was unaware that Resident 1 was refusing medications. The DON stated Resident 1 had refused Haloperidol since the first day of his admission on [DATE], but there was no COC was done until 6/12/2025. The DON stated the licensed nurses did not follow up with Resident 1's COC for further instruction from the physician, and did not inform the DON about Resident 1's COC. The DON stated the facility did not conduct an IDT and did not develop a care plan to address Resident 1's COC of refusing medications. The DON stated it was important for the licensed nurses to monitor Resident 1's behavior of refusing psychotropic medication closely, and report Resident 1 refusal of medications to the physician, to manage and intervened Resident 1's mental condition timely and effectively. The DON stated the facility did not monitor, communicate, address and intervene regarding Resident 1's behavior of frequent refusal of psychotropic medications, which had resulted in Resident 1 not receiving medications as ordered by the physician. The DON stated since Resident 1 was not receiving the prescribed medications, this could have resulted in why Resident 1 allegedly pushed Resident 2, and Resident 1 being transferred to the GACH for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 3 of 4 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 07/09/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 5150 on 6/20/25. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated 3/2019, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance. The P&P indicated the staff will assess, evaluate and identify, document, and inform the physician and RP about changes in an individual's mental status, behavior and cognition, then, IDT will evaluate and identify the cause of the changes, and intervene and manage the condition. During a review of the facility's policy and procedure (P&P) titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2021, the P&P indicated If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident/representative to a. determine why he or she is requesting, refusing or discontinuing care or treatment; b. try to address his or her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences (positive and negative) of the decision, If the decision to refuse or discontinue treatment results in a significant change of condition, a reassessment will occur and appropriate changes will be made to the resident's care plan. The P&P indicated detailed information relating to the refusal of treatment are documented in the resident's medical record, including the practitioner's response. The P&P indicated the practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. Event ID: Facility ID: 056190 If continuation sheet Page 4 of 4