Health inspection·January 2, 2026

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4's admission Record indicated the resident was admitted on [DATE] with diagnoses that included pneumonia (a lung infection), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 4's H&P, dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE] the MDS, indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 5's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included COPD, muscle weakness, and hypertension. During a review of Resident 5's H&P, dated [DATE], indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS, indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 6's admission Record indicated the resident was admitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and CKD. During a review of Resident 6's H&P, dated [DATE], the H&P indicated that the resident has fluctuating capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 7's admission Record indicated the resident was admitted on [DATE] with diagnoses that included quadriplegia (paralysis affecting all four limbs and the torso, usually from a spinal cord injury in the neck but also from brain trauma or disease), muscle weakness, and hypertension. During a review of Resident 7's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 8's admission Record indicated the resident was admitted on [DATE] with diagnoses that included COPD, bipolar disorder (a mental health condition causing extreme mood swings), and depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting thoughts, feelings, and daily life). During a review of Resident 8's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated that the resident has intact cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 9's admission Record indicated the resident was admitted on [DATE] with diagnoses that included CKD, dementia, and hypothyroidism (a condition where the thyroid gland doesn't make enough thyroid hormone). During a review of Resident 9's H&P, dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 10's admission Record indicated the resident was admitted on [DATE] with diagnoses that included diabetes mellitus, muscle weakness, and endocarditis (a serious inflammation of the heart's inner lining and valves). During a review of Resident 10's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 10's MDS, dated [DATE], the MDS indicated that the resident has severely impaired cognition. The MDS also indicated that the resident did not have a POLST in the resident's medical records. During a review of Resident 11's admission Record indicated the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 2 of 36 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 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many admitted on [DATE] with diagnoses that included diabetes mellitus, intracerebral hemorrhage (bleeding in the brain), and hypertension. During a review of Resident 11's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 11's MDS, dated [DATE], the MDS indicated that the resident MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During an interview on [DATE] at 11:47 AM with licensed vocational nurse (LVN) 1, LVN 1 stated that on [DATE] at around 3 PM to 3:15 PM, Registered Nurse (RN) 1 went into Nursing Station (NS) 3 to check Resident 1's medical chart and identify what Resident 1's code status was. LVN 1 stated that RN 1 could not locate Resident 1's POLST. LVN 1 stated that after not being able to find the resident's POLST, RN 1 instructed the nurses to initiate CPR. LVN 1 stated when a POLST or a code status order was not found, the resident was treated as full code (a patient wants all possible life-saving measures, including CPR [chest compressions, defibrillation], intubation [breathing tube], and mechanical ventilation, if their heart stops or they stop breathing). During a telephone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE] at around 3 PM, LVN 2 informed her in NS 1 that Resident 1 was unresponsive and pulseless. RN 1 stated that she went from NS 1 to NS 3 to look for Resident 1's code status. RN 1 stated that she could not find Resident 1's POLST or code status in Resident 1's current medical chart. RN 1 stated that she instructed the nurses to initiate CPR since there was no POLST or code status, therefore Resident 1 was treated as full code. During an interview on [DATE] at 4:53 PM with the Director of Nursing (DON), the DON stated that the facility could not find Resident 1's POLST or Advance Directive (AD a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in the current medical chart. DON stated that the POLST or AD might be in the resident's old chart, since the POLST or AD was not in Resident 1's current medical chart. During a concurrent interview and record review on [DATE] at 8:47 AM with the DON, Resident 1's POLST, dated [DATE], was reviewed. The DON stated that she had found Resident 1's POLST in the resident's previous medical chart. The DON stated that the document was still valid on [DATE] when Resident 1 was found unresponsive. The DON stated that the POLST was part of the resident's AD and the AD should have been placed in the resident's current chart since the nurses look for the POLST when a resident was found unresponsive to determine if CPR should be performed. The DON further stated that not having the POLST or AD in the chart could cause a delay in performing CPR during a medical emergency. During a concurrent interview and record review on [DATE] at 11:38 PM with RN 3, the electronic and current medical charts of the facility's 100 residents were reviewed for their completeness, including the presence of a POLST and AD. During the record review, the records of Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11 did not include a POLST or AD. RN 3 stated that she could not find the residents' POLST or AD. RN 3 stated that the POLST or AD must be in the charts because the nurses need the POLST or AD during a medical emergency to ensure the residents wishes were performed and that facility staff follow the residents wishes. The RN 3 stated a medical emergency example was when a resident was found unresponsive and pulseless. During a concurrent interview and record review on [DATE] at 3:35 PM with Social Worker (SW) 1, Resident 2's records were reviewed. SW 1 stated Resident 2's POLST was on SW 1's email and not placed in Resident 2's medical chart. SW 1 stated that the POLST must be printed and in the resident's physical chart. During a concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 3's records were reviewed. SW 1 stated that Resident 3's POLST was not in the resident's records because the resident was transferred (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 3 of 36 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 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 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] 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] 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] 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] 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] 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] 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] 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. Event ID: Facility ID: 056190 If continuation sheet Page 4 of 36 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 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 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that direct care staff were qualified to respond and perform cardiopulmonary resuscitation (CPR) for one out of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1). After further investigation, it was determined the facility failed to ensure that: 1.On [DATE], CNA 1, Registered Nurse (RN) 1, LVN 1, LVN 2, and LVN 5 did not call a code blue immediately when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM. 2. On [DATE], LVN 1 and CNA 2 did not place Resident 1 on a firm, flat surface while performing CPR. LVN 1 and CNA 2 did not use the backboard (a rigid board inserted under a patient's back to create a firm surface, preventing soft surfaces [like mattresses] from absorbing compression force, thereby improving the depth and effectiveness of chest compressions) that was available at the facility. 3. On [DATE], LVN 1 and CNA 2 did not perform rescue breaths on Resident 1 while performing CPR on [DATE],?in accordance with?professional standard of practice?and?the?2025?American Heart Association?(AHA)?Guidelines for?CPR. 4.On [DATE], LVN 1 and CNA 2 did not perform continuous and appropriate chest compressions with the required depth on Resident 1, in accordance with professional standard of practice and the 2025 AHA Guidelines for CPR. As a result, Resident 1 was pronounced deceased (dead) on [DATE] at 3:48 PM by EMS crew after 20 minutes of CPR. As a result of these deficiencies, the facility placed 66 full code (a patient wants all possible life-saving measures if their heart or breathing stops, including CPR) residents at risk to not receive adequate and proper life-saving measures during a code blue, potentially leading to greater harm and/or death to other residents residing in the facility. Cross referenced to F678 Findings:? During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide). ? During a review of Resident 1's POLST (Physician Orders for Life-Sustaining Treatment,?a portable medical order form that helps seriously ill or frail individuals specify their end-of-life care wishes, such as CPR), dated?[DATE],?and signed by Resident 1,?the POLST instructed staff?to attempt CPR?if?Resident 1?has? no pulse and is not breathing.?? ? During a review of?Resident?1's History and Physical (H&P), dated?[DATE],?the H&P?indicated?the resident?does not?have the capacity to understand and make decisions.? During a review of?Resident?1's Minimum Data Set (a resident assessment tool), dated?[DATE],?the MDS?indicated that Resident 1 has severely impaired cognition (the ability to?process thoughts and emotions).?The MDS also?indicated?that the resident?did not have a life expectancy of less than 6 months at the time of assessment.?The MDS further?indicated?that the resident?did not have a POLST (---) in the resident's chart.? ? ? During a review of Resident 1's?Interdisciplinary Team (IDT) Conference Record Notes, dated?[DATE],?the IDT?indicated?that?Resident 1's code status was Full code and that staff should?attempt?CPR when necessary.? ? During a review of Resident 1's Physician Progress Notes, dated?[DATE], the Notes?indicated?that Resident?1 had a code status of Full Code- Attempt CPR.? During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On?[DATE],?timed at 4:10 PM,?and?signed?by?RN?1,?the?note?indicated?that at 3:15 PM,?the charge nurse?reported to [RN 1] that?she saw [Resident 1] unresponsive during rounds (scheduled nurse visits to patient's bedside to assess, monitor and address patient needs). The?note further?indicated?that RN 1?went to the resident's room to assess Resident 1 and?could Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 5 of 36 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 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 not?obtain the resident's blood pressure. The?note?also?indicated?that RN 1 instructed one of the team members to start CPR right away. The?note?indicated?that CPR was continued until the?Emergency Medical Services crew from the local Fire Department (FD)?arrived?at 3:29 PM. The note further?indicated?that?the resident was pronounced deceased at 3:48 PM.? 2. On [DATE], timed at 4:47 PM, and signed by LVN 1, the note indicated that at 3:05 PM, the CNA [CNA1] reported [to LVN 1 that resident was unresponsive. The note indicated that Resident 1 did not have a pulse or blood pressure. The note also indicated chest compressions were performed until the EMS crew came and took over. The note further indicated that Resident 1's time of death was on [[DATE]] at 3:48 PM. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 1, dated [DATE], the SOD indicated that at 3:17 PM, [CNA 1] told [LVN 1] that [Resident 1] is unresponsive. The SOD indicated LVN 1, RN 1, and RN 2 reported to the resident's room. The SOD stated that chest compressions started at 3:22 PM initially. The SOD also indicated that RN 2, LVN 1, and CNA 2 were performing chest compressions until the EMS crew arrived. The SOD indicated that compressions were performed [at] 30 [per minute]. The SOD indicated RN 1 and RN 2 went into the Nurse's Station to check for Resident 1's POLST. The SOD further indicated that Resident 1's POLST could not be found and [RN 1 and RN 2] stated to initiate CPR. The SOD indicated that when a resident is found to be unresponsive, the resident's POLST is checked, and after that, CPR is initiated. ? During a review of a Statement of Declaration (SOD) titled, Declaration, signed by RN 3, dated [DATE], the SOD indicated that before doing CPR [staff] [has] to check [the] code status of the resident. ?? During a follow-up interview?on [DATE] at 11:11 AM with RN 3, RN 3?stated?that?the rate of compression during a CPR is 30 compressions per minute. During an interview on [DATE] at 11:38 AM with LVN 1, LVN 1 stated that when a resident is found unresponsive, the responding staff should go straight for airway. LVN 1 stated the next step is to assess the resident's circulation by checking the resident's pulse. LVN 1 stated that chest compressions should be initiated if the resident is determined to be pulseless at a rate of 30 compressions per minute. ? During another interview on [DATE] at 11:47?AM with LVN 1,? LVN 1 stated he worked on [DATE] when Resident 1 was found unresponsive. LVN 1 stated that on [DATE], at around 3:15 PM, CNA 1 informed him that Resident 1 was unresponsive. LVN 1 stated that he and other nurses, including RN 1 and RN 2, assessed the resident and found that the resident was not breathing and did not have a pulse. LVN 1 stated that RN 1 and RN 2 went into the nurse's station to check Resident 1's records and locate Resident 1's code status. LVN 1 stated that RN 1 was the one who instructed staff (LVN 1 and CNA 2) to start CPR on Resident 1. LVN 1 stated he could not recall who first initiated chest compressions to Resident 1 and who administered rescue breaths. LVN 1 also stated he could not recall if a backboard was used during Resident 1's CPR. During a phone interview on [DATE] at 12:27 PM with CNA 1, CNA 1 stated she went into Resident 1's room on [DATE] at around 3:10 PM to 3:15 PM and found Resident 1 sitting up in bed and unresponsive. CNA 1 stated that she shook Resident 1 and still unresponsive. CNA 1 stated she did not initiated CPR right away on Resident 1 but instead went out of the resident's room to inform LVN 2 then LVN 1. ? During a phone interview on [DATE] at 12:43 PM with LVN 2, LVN 2 stated that on [DATE] at around 3:10 PM, she went inside Resident 1's room and observed that Resident 1 was pale and not breathing. LVN 2 stated she assessed Resident 1 by checking the pulses in both arms and neck and found that the resident did not have a pulse. LVN 2 stated that she went out of Resident 1's room and went to Nursing Station 1 to notify RN 1. LVN 2 stated she did not initiate CPR right away and could not remember who initiated chest compressions to Resident 1. LVN 2 stated she went back to Resident 1's room. LVN 2 added she could not remember if anyone put the backboard under Resident 1 and if the Ambu-bag was used to give Resident 1 rescue breaths. During a phone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 6 of 36 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 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 interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE], at around 3:00 PM to 3:15 PM, she was at Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive and had no pulse. RN 1 stated that she went to Nursing Station 3 to check Resident 1's records and look for Resident 1's code status. RN 1 stated that when she found out Resident 1 was full code, that was when she informed the other nurses (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) in the room to initiate CPR on Resident 1. RN 1 stated that the nurses that were inside Resident 1's room was waiting for her to check Resident 1's code status. RN 1 stated that she could not recall who initiated CPR on Resident 1, could not recall if the Ambu-bag was used, or if the backboard was placed under Resident 1. During another interview on [DATE] at 1:36 PM with LVN 1, LVN 1 stated that on [DATE] at around 3:15 PM, RN 1 and RN 2 searched for Resident 1's code status in Nursing Station 3. LVN 1 stated that when RN 1 and RN 2 could not find the code status, RN 1 and RN 2 instructed facility staff (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) to initiate CPR on Resident 1. During another phone interview on [DATE] at 2:38 PM with LVN 2, LVN 2 stated that on [DATE] when she found Resident 1 unresponsive, she activated code blue by going to Nursing Station 1 to notify RN 1. LVN 2 stated she did not stay with the resident to initiate CPR. During a phone interview on [DATE] at 2:51 PM with RN 2, RN 2 stated that on [DATE] at around 3:20 PM, she entered Resident 1's room and found LVN 1 and LVN 5 assessing Resident 1. RN 2 stated that LVN 1 and LVN 5 informed her that Resident 1 did not have a pulse. RN 2 stated that RN 1 instructed them to start and initiate CPR on Resident 1. RN 2 stated that CPR was started after RN 1 instructed them to initiate CPR (after RN 2's arrival in Resident 1's room at 3:20 PM). RN 2 stated she could not remember who provided rescue breaths to Resident 1. RN 2 stated she could not remember if a backboard was placed under Resident 1. RN 2 further stated that when the EMS crew arrived, the EMS crew placed Resident 1 on the floor and continued CPR on the floor. During another phone interview on [DATE] at 3:44 PM with CNA 1, CNA 1 stated that when she found Resident 1 unresponsive on [DATE] at around 3:, she did not check Resident 1's pulse or respirations. CNA 1 stated she did not call for help by shouting code blue. CNA 1 added she did not initiate CPR. ? During a phone interview on [DATE] at 4:16 PM with EMS Crew, Paramedic (PC) 1, PC 1 stated that on [DATE], PC 1 and PC 2 responded to the facility's 911 call for a resident that was unresponsive. PC 1 stated that on [DATE] upon arriving in Resident 1's room, PC 1 stated he observed two facility staff members were next to Resident 1, and one more facility staff member was performing CPR. PC 1 stated Resident 1 was wearing a non-rebreather mask and staff was not using an Ambu-bag. PC 1 stated that an oxygen mask like the non-rebreather mask was not an appropriate equipment to use while conducting a CPR. PC 1 stated that the Ambu-bag was observed right next to Resident 1's head of the bed but was not being used by the facility staff because it was not inflated and not connected to an oxygen source. PC 1 also stated that the EMS crew had to move Resident 1 from the bed to the floor because Resident 1 was not placed under a backboard while on the bed. PC 1 stated that the EMS crew continued to perform CPR on Resident 1 for about 15 more minutes. ? During a phone interview on [DATE] at 4:43 PM with another EMS Crew, PC 2, PC 2 stated that on [DATE] when the EMS crew responded to the facility's 911 call, PC 2 observed one facility staff member perform CPR on Resident 1. PC 2 stated that the facility staff member was not performing adequate CPR because the rate was inconsistent and slow and the facility staff's compressions would stop and go and stop. PC 2 further stated that during his observation, the facility staff member performing the CPR was only using one hand, instead of two hands during chest compressions. PC 2 stated that the facility staff performing the CPR were not using the Ambu-bag to provide rescue breaths because Resident 1 was placed on a non-breather mask. PC 2 further stated that the facility staff did not place Resident 1 on a backboard and performed CPR on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 7 of 36 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 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 the bed. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 5, dated [DATE], the SOD indicated that on [DATE] at around 3:15 PM, LVN 5 heard CNA 1 informing LVN 2 that Resident 1 was unresponsive. The SOD indicated that LVN 5 observed LVN 2 ran towards [Nursing] Station 1. The SOD indicated that LVN 5 assessed Resident 1 and the resident looked pale, unresponsive, and pulseless. The SOD indicated that LVN 5 recalled how LVN 2 searched for Resident 1's code status in the resident's electronic records and could not find Resident 1's code status. The SOD indicated that LVN 5 recalled that LVN 2 asked the facility's Social Worker (SW 2) regarding Resident 1's code status, and SW 2 stated that Resident 1's code status was full code and started CPR. ? During an interview on [DATE] at 9:37 AM, LVN 5 stated that on [DATE] at around 3 PM, she heard CNA 1 informed LVN 2 that Resident 1 was unresponsive. LVN 5 stated she instructed LVN 2 to get the Emergency Cart, however, LVN 2 went to Nursing Station 1. LVN 5 stated she assessed Resident 1 and the resident was unresponsive, pale, and pulseless. LVN 5 stated that LVN 1, RN 2, and SW 2 were inside Resident 1's room. LVN 5 stated she went out of Resident 1's room to search for Resident 1's code status in the resident's physical chart. LVN 5 stated she needed to know Resident 1's code status before starting CPR. During an interview on [DATE] at 10:24 AM with LVN 5, LVN 5 stated that if a resident is unresponsive and pulseless, staff must make sure that the resident is a full code before initiating CPR. LVN 5 added that the chest compression rate for an effective CPR is 30 compressions per minute. LVN 5 also added that a non-rebreather mask may also be used during CPR. ? During a phone interview on [DATE] at 10:29 AM with CNA 2, CNA 2 stated that on [DATE], he participated in performing CPR on Resident 1. CNA 2 stated he performed CPR at 80 compressions per minute because Resident 1 was fragile. CNA 2 stated that when the EMS arrived, CNA 2 and another LVN (LVN 2) was performing CPR on Resident 1. CNA 2 stated that he could not remember if an Ambu-bag was used on Resident 1. CNA 2 also stated that he could not recall if a backboard was placed under Resident 1. ? During an interview on [DATE] at 10:45 AM with 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 Emergency Cart into Resident 1's room. LVN 4 stated that RN 1 instructed the nurses to perform CPR on Resident 1. LVN 4 stated she could not remember who used the Ambu-bag. LVN 4 stated she could not recall who put the backboard under Resident 1. During an interview on [DATE] at 10:48 AM with LVN 6, LVN 6 stated that if a resident is found unresponsive and pulseless, she would call an RN. LVN 6 stated that after calling for an RN, call 911 and check for the resident's code status. LVN 6 stated that after those steps, she would initiate CPR by laying the resident flat and starting chest compressions. ? During an interview?on?[DATE] at 3:07 PM with the Director of Nursing (DON),?the DON?stated?that when a staff member finds that a resident is unresponsive,?the staff member should?check the resident's?vitals?signs, 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?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?2 rescue?breathing?in between?30 compressions.?The DON also added that CPR must be?performed at a rate of 100 to 120 compressions per minute.?? ? During a phone interview on [DATE] at 4:31 PM with Medical Doctor (MD) 1, MD 1?stated?that when a resident is found to be unresponsive,?facility staff are expected to initiate CPR right away. MD 1?stated?that staff should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 8 of 36 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 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 not prioritize looking for?the resident's code status because if CPR is not?initiated?immediately, the resident could suffer prolonged cardiac arrest and, eventually, death.? ? During a concurrent interview and record review on [DATE] at 11:41 AM with the DON, Resident 1's medical records were reviewed, including the progress notes. The DON stated the progress notes indicated that on [DATE] at 3:05 PM, a CNA reported to LVN 1 that Resident 1 was unresponsive. The DON stated that at 3:15 PM, another nurse informed RN 1. The DON stated that RN 1 instructed staff to perform CPR. The DON stated that CPR was delayed and it should have been initiated right away. ? During the same concurrent interview and record review on [DATE] at 11:41 AM with the DON, the facility's policy and procedures (P&P) titled,? Emergency Procedure- Cardiopulmonary Resuscitation, dated 2/2018, was reviewed. The DON?stated?that?the P&P?indicates?that?CPR must be?initiated?until the resident is determined to be DNR. The DON?stated?that?the P&P?indicates?that CPR compressions must be?at a rate of at least 100 compressions per minute.?The DON?stated?that the P&P also?indicates?that?supplies necessary for CPR must?always be readily available.?The DON added that the EC must?contain?a backboard and?Ambu-bag.?? ? During a phone interview on [DATE] at 3:49 PM with MD 2, MD?2?stated?that?facility staff must follow the facility's P&P?in the event?of?a code blue.?MD 2 added?that during a code blue, CPR must be?initiated?right away.? During a review of the facility's job description (JD) for a CNA titled, Certified Nursing Assistant,?undated, the JD?indicated?that?a CNA's?job function?includes?initiating?CPR and?assisting?with code procedures.?? ? During a review of the facility's job description (JD) for an LVN titled, Charge nurse- LVN,?undated, the JD?indicated?that?a LVN's job function includes?responding and directing care in? emergency situations using good judgement and established policies and procedures.?The JD also?indicated?that the LVN initiates CPR and directs code procedures.? During a review of the American Heart Association's guidelines published on [DATE], titled, 2025 American Heart Association Guidelines for CPR and ECC, https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support, [site accessed on [DATE]], the guidelines indicated the following: 1.If a resident is found unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the health care professional should check for a pulse for no more than 10 seconds and, if no definite pulse is felt, should assume the person is in cardiac arrest. 2. After identifying an adult in cardiac arrest, a lone responder should activate the emergency response system first, then immediately begin CPR, beginning with chest compressions. 3. In adult cardiac arrest, it is preferred to perform CPR on a firm surface and with the person in the supine position, when feasible and does not delay chest compressions. 4. 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's?P&P titled,? Emergency Procedure- Cardiopulmonary Resuscitation,?dated 2/2018,?the P&P?indicated?that?the following:? 1.The?chances of a resident surviving a cardiac arrest may be increased if CPR is initiated immediately.? 2. If a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR.? 3. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010?American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material.? 4. Maintain equipment and supplies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 9 of 36 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 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: 056190 If continuation sheet Page 10 of 36 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 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 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure proper and effective Basic Life Support (BLS-the level of care provided to victims of life-threatening illnesses or injuries until full medical care is available, including recognition of cardiac arrest and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). The facility did not continuously perform BLS for one of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1) during a code blue (a life-threatening medical emergency requiring an immediate trained response for CPR) when Resident 1 was found unresponsive, pulseless, and not breathing by failing to ensure: 1. Certified Nursing Assistant (CNA) 1, Registered Nurse Supervisor (RN) 1, Licensed Vocational Nurse (LVN) 1, LVN 2, and LVN 5 immediately called a code blue when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM, so that CPR could be initiated without delay. 2. CNA 1, RN 1, LVN 1, LVN 2, and LVN 5 were aware of Resident 1's code status (a medical order indicating the type of emergency treatment a person would or would not receive if their heart or breathing stopped) and were able to locate this information in the resident's medical record. LVN 1 stated that CPR was initiated by a licensed nurse on the resident's bed at 3:22 PM on [DATE], approximately 12 minutes after the resident was found unresponsive. 3. LVN 1 and CNA 2 placed Resident 1 on a firm, flat surface while performing CPR on the resident's bed and utilized a backboard available at the facility, designed to provide a rigid surface under the resident's back to prevent mattress compression and improve the depth and effectiveness of chest compressions during CPR. 4. LVN 1 and CNA 2 performed continuous and uninterrupted CPR on the resident's bed until emergency medical services (EMS- ambulance services or emergency services that provide treatment and stabilization for the patient) assumed care. As a result, Resident 1 was pronounced deceased (dead) on [DATE] at 3:48 PM by EMS crew after 20 minutes of CPR were performed on the floor. These failures placed the facility's identified 66 full code residents at risk to not receive adequate and proper life-saving measures during a code blue, potentially leading to greater harm and/or death to other residents residing in the facility. On [DATE] at 2:34 PM, an Immediate Jeopardy (IJ: a situation in which the facility's' noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) regarding the facility's failure to ensure Resident 1 adequately and continuously received BLS, including CPR, resulting in Resident 1's death on [DATE]. On [DATE] at 4:13 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 6:13 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, record review, and determined that the IJ situation was no longer present, the IJ was removed onsite on [DATE] at 6:13 PM, in the presence of the ADM and the Director of Nursing (DON). After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope of isolated (when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved) and lower severity of Level 2 (noncompliance with the requirements for participation that results in the potential for no more than minimal physical, mental, and/or psychosocial harm to the resident, but has the potential to result in more than minimal harm that is not immediate jeopardy). On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 11 of 36 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 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 [DATE] at 6:13 PM, the IJ was removed, in the presence of the ADM and the DON after the facility submitted an acceptable IJ Removal Plan. The surveyor verified and confirmed the implementation of the IJ Removal Plan while onsite through observation, interview, and record review. The acceptable IJ Removal Plan included the following: On [DATE], Quality Assurance Nurse (QA) and the RN on duty initiated a review of the current residents' care profile in the facility's electronic health record (EHR) system, Code Status. The QA and the RN verified the residents' Code Status via Physician Orders for Life-Sustaining Treatment (POLST -a portable medical order form that helps seriously ill or frail individuals specify their end-of-life care wishes, such as CPR) forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status so that the information is readily available for facility staff, including such events as a Code Blue to ensure all residents who have a full code status receive effective BLS, including CPR. Out of 100 current residents, 66 residents have Full Code status. On [DATE], a copy of the list of these Full Code residents was readily available to staff at the nurse's station for reference and will be updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed. On [DATE] and ongoing, the DON/Designee provided in-service education to nursing staff regarding the availability of the list of residents who are Full Code. On [DATE], the DON checked the EC and ensured that CPR backboard is available. The RN and/or Designated Licensed Nurse conducted inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This was validated by the DON and/or Designee. The RN and/or Designated Licensed Nurse will conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard. On [DATE] and ongoing, the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly. On [DATE], the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding providing rescue breathing (a type of first aid that's given to people who have stopped breathing), not placement of a non-rebreather mask (medical device that delivers high concentrations of oxygen to individuals who can breathe independently but have low blood oxygen). The DON will provide continued in-services for all of the facility's RNs, LVNs, and CNAs. On [DATE], the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly. The DON will provide continued in-services for all facility's Licensed Nurses and CNAs. On [DATE], the Director of Staff Development (DSD) reviewed employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date. There are currently 102 active Direct Care Staff employed at the facility with a total of 16 RNs, 25 LVNs, and 61 CNAs are currently employed at the facility. One LVN (LVN 2) and one CNA do not have a current CPR/BLS certification. On [DATE], the identified CNA attended the CPR certification training. The CNA will be put on temporary suspension until CPR certification is received as part of Direct Care Staff competency. The identified LVN that did not have a current CPR/BLS certification has been placed on suspension and will not be permitted to return to work without an active certification for CPR/BLS. Multiple attempts have been made to contact the LVN with no response at this time. Clinical Nurse Consultant provided 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards. On [DATE], the DON/Designee provided in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures Cardiopulmonary Resuscitation with emphasis on immediate code activation and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 12 of 36 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 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 calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil (allowing the chest to completely return to its normal, resting position between compressions) and minimal interruptions. DON/Designee will provide in-service to LVN 2 upon returning to work. LVN 2 will not be on the schedule until education/reeducation was provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation. On [DATE], the DON/Designee provided in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasize on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions. On [DATE], a Certified CPR instructor came to the facility and provided mandatory re-education and training for all Licensed Nurses and CNAs which was also attended by the DON and DSD with return demonstration conducted. A series of ongoing CPR Certification Training sessions will be provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training to ensure all residents who have a full code status receive effective BLS, including CPR when the needs arise and prevent greater harm and/or death. Additionally, a Code Blue drill (training) was initiated on [DATE] and will continue weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR. An RN is designated as the team leader for Code Blue emergencies. On [DATE], additional CPR training will be provided by a Certified CPR Instructor to provide mandatory (required) re-education and training for all Licensed Nurses and CNAs with return demonstration. Any Licensed Nurses or CNAs will not be permitted to work directly with patients if they do not complete the Certified CPR refresher course. Quality Assurance and Performance Improvement (QAPI, a mandatory facility program to systematically monitor and enhance the quality of care and life for residents) Monitoring Plan Effective [DATE]: The DSD/Designee will maintain a log for all Direct Care Staff of their active Certification for BLS/CPR. DSD/Designee will notify staff with BLS/CPR certification expiring within a month. DSD/Designee will present to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification. As part of QAPI and Compliance on BLS/CPR, no Direct Care Staff will be permitted to work directly with patients without an active BLS/CPR certification. QAA Committee, on a monthly basis, will review audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions. Cross referenced to F659 Findings: During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (a serious condition when not enough oxygen passes from a person's lungs to the blood). During a review of Resident 1's POLST, dated [DATE], and signed by Resident 1, the POLST instructed staff to attempt CPR if Resident 1 had no pulse and is not breathing. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated [DATE], the MDS indicated that Resident 1 has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident did not have a life expectancy of less than 6 months at the time of assessment. The MDS further indicated that the resident did not have a POLST in the resident's chart. During a review of Resident 1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 13 of 36 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 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 Interdisciplinary Team (IDT) Conference Record Notes, dated [DATE], the IDT indicated that Resident 1's code status was Full code and that staff should attempt CPR when necessary. During a review of Resident 1's Physician Progress Notes, dated [DATE], the Notes indicated that Resident 1 had a code status of Full Code- Attempt CPR. The Notes also indicated a plan to continue regular breathing treatments as scheduled. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On?[DATE],?timed at 4:10 PM,?and?signed?by?RN?1,?the?note?indicated?that at 3:15 PM,?the charge nurse?reported to [RN 1] that?she saw [Resident 1] unresponsive during rounds (scheduled nurse visits to patient's bedside to assess, monitor and address patient needs). The?note further?indicated?that RN 1?went to the resident's room to assess Resident 1 and?could not?obtain the resident's blood pressure. The?note?also?indicated?that RN 1 instructed one of the team members to start CPR right away. The?note?indicated?that CPR was continued until the?Emergency Medical Services crew from the local Fire Department (FD)?arrived?at 3:29 PM. The note further?indicated?that?the resident was pronounced deceased at 3:48 PM.? 2. On [DATE], timed at 4:47 PM, and signed by LVN 1, the note indicated that at 3:05 PM, the CNA [CNA1] reported [to LVN 1] that resident was unresponsive. The note indicated that Resident 1 did not have a pulse or blood pressure. The note also indicated chest compressions were performed until the EMS crew came and took over. The note further indicated that Resident 1's time of death was on [[DATE]] at 3:48 PM. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 1, dated [DATE], the SOD indicated that at 3:17 PM, [CNA 1] told [LVN 1] that [Resident 1] is unresponsive. The SOD indicated LVN 1, RN 1, and RN 2 reported to the resident's room. The SOD stated that chest compressions started at 3:22 PM initially. The SOD also indicated that RN 2, LVN 1, and CNA 2 were performing chest compressions until the EMS crew arrived. The SOD indicated that compressions were performed [at] 30 [per minute]. The SOD indicated RN 1 and RN 2 went into the Nurse's Station to check for Resident 1's POLST. The SOD further indicated that Resident 1's POLST could not be found and [RN 1 and RN 2] stated to initiate CPR. The SOD indicated that when a resident is found to be unresponsive, the resident's POLST is checked, and after that, CPR is initiated. During a review of the SOD titled, Declaration, signed by RN 3, dated [DATE], the SOD indicated that before doing CPR [staff] [has] to check [the] code status of the resident. During a review of the facility's staffing schedule titled, Monthly Work Schedule, the staffing schedule indicated the following information: 1.For CNA 3, for the month of [DATE], the schedule indicated that CNA 3 started working at the facility on [DATE]. The facility staffing schedule indicated CNA 3 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and[DATE]. 2. For CNA 3, for the month of [DATE], the schedule indicated that CNA 3 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3. For LVN 2, for the month of [DATE], the schedule indicated that LVN 2 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 4. For LVN 2, for the month of [DATE], the schedule indicated LVN 2 performed work at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During a review of a facility document titled, Emergency Cart Checklist, dated for the month of [DATE], the document indicated a list of equipment and medication contents required to be included in the facility's EC. The checklist indicated that all the contents of the EC were marked off as present and the daily inventory for [DATE] was completed, which included an Adult Ambu-bag with connective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 14 of 36 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 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 tubing (a thin plastic tubing that attaches to an oxygen source). During a concurrent interview and record review of the facility's [DATE] Emergency Cart Checklist on [DATE] at 9:46 AM with RN 3, RN 3 stated that the check marks in the checklist indicated that the item was checked and available in the EC. RN 3 further stated that she completed the inventory of the EC and checked off the EC checklist for [DATE]. During a follow up observation of the EC on [DATE] at 9:46 AM, in the presence of RN 3, the EC contents were inspected for completeness. During the observation, the EC did not contain an Ambu-bag. During a concurrent interview on [DATE] at 9:46 AM with RN 3, RN 3 stated Ambu-bags are used for CPR during a code blue. RN 3 stated it was her responsibility to inspect the EC at the beginning of the shift at 7:30 AM. RN 3 stated she completed and signed the EC checklist but did not actually inspect the entire contents of the EC because she was busy. During a follow-up interview on [DATE] at 11:11 AM with RN 3, RN 3 stated the correct procedure when inspecting the EC is to go over the EC contents one-by-one to make sure everything is there. RN 3 further stated that the Ambu-bag is important because in order to perform an effective CPR, an Ambu-bag is used to give rescue breaths to the resident. RN 3 also stated that the Ambu-bag might have been taken out of the EC during the code blue on [DATE]. RN 3 stated the Ambu-bag was probably not replaced when it was taken out on [DATE] during the code blue situation. RN 3 further stated that the EC contents must be re-stocked by the licensed nurses when the contents are used, as soon as possible. During a follow-up interview?with RN 3 on [DATE] at 11:11 AM, RN 3?stated?that?the rate of compression during a CPR is 30 compressions per minute. During an interview on [DATE] at 11:47 AM with LVN 1, LVN 1 stated he worked on [DATE] when Resident 1 was found unresponsive. LVN 1 stated that on [DATE], at around 3:15 PM, CNA 1 informed him that Resident 1 was unresponsive. LVN 1 stated that he and other nurses, including RN 1 and RN 2, assessed the resident and found that the resident was not breathing and did not have a pulse. LVN 1 stated that RN 1 and RN 2 went into the nurse's station to check Resident 1's records and locate Resident 1's code status. LVN 1 stated that RN 1 was the one who instructed staff (LVN 1 and CNA 2) to start CPR on Resident 1. LVN 1 stated he could not recall who first initiated chest compressions to Resident 1 and if anyone was giving rescue breaths. LVN 1 also stated he could not recall if a backboard was used during Resident 1's CPR while the resident was on the bed. During a phone interview on [DATE] at 12:27 PM, CNA 1 stated that on [DATE], at approximately 3:10 PM to 3:15 PM, she entered Resident 1's room and found Resident 1 sitting up in bed and unresponsive. CNA 1 reported that she attempted to shake Resident 1, but the resident remained unresponsive. CNA 1 further stated that she did not initiate CPR immediately; instead, she left the room to inform LVN 2, followed by LVN 1. During a phone interview on [DATE] at 12:43 PM with LVN 2, LVN 2 stated that on [DATE] at around 3:10 PM, she went inside Resident 1's room and observed that Resident 1 was pale and not breathing. LVN 2 stated she assessed Resident 1 by checking the pulses in both arms and neck and found that the resident did not have a pulse. LVN 2 stated that she went out of Resident 1's room and went to Nursing Station 1 to notify RN 1. LVN 2 stated she did not initiate CPR right away and could not remember who initiated chest compressions to Resident 1. LVN 2 stated she went back to Resident 1's room. LVN 2 added she could not remember if anyone put the backboard under Resident 1 and if the Ambu-bag was used to give Resident 1 rescue breaths. During a phone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE], between the hours of 3:00 PM to 3:15 PM, she was at Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive and had no pulse. RN 1 stated that she went to Nursing Station 3 to check Resident 1's records and look for Resident 1's code status. RN 1 stated that when she found out Resident 1 was full code, that was when she informed the other nurses (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) in the room to initiate CPR on Resident 1. RN 1 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 15 of 36 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 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 that the nurses that were inside Resident 1's room were waiting for her to check Resident 1's code status. RN 1 stated that she could not recall who initiated CPR on Resident 1, could not recall if the Ambu-bag was used, or if the backboard was placed under Resident 1. During another interview on [DATE] at 1:36 PM with LVN 1, LVN 1 stated that on [DATE] at around 3:15 PM, RN 1 and RN 2 searched for Resident 1's code status in Nursing Station 3. LVN 1 stated that when RN 1 and RN 2 could not find the code status, RN 1 and RN 2 instructed facility staff (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) to initiate CPR on Resident 1. During another phone interview on [DATE] at 2:38 PM with LVN 2, LVN 2 stated that on [DATE] when she found Resident 1 unresponsive, she activated code blue by going to Nursing Station 1 to notify RN 1. LVN 2 stated she did not stay with the resident to initiate CPR. During a phone interview on [DATE] at 2:51 PM with RN 2, RN 2 stated that on [DATE] at around 3:20 PM, she entered Resident 1's room and found LVN 1 and LVN 5 assessing Resident 1. RN 2 stated that LVN 1 and LVN 5 informed her that Resident 1 did not have a pulse. RN 2 stated that RN 1 instructed them to start and initiate CPR on Resident 1. RN 2 stated that CPR was started after RN 1 instructed them to initiate CPR (after RN 2's arrival in Resident 1's room at 3:20 PM). RN 2 stated she could not remember who provided rescue breaths to Resident 1. RN 2 stated she could not remember if a backboard was placed under Resident 1 because when the EMS crew arrived, the EMS crew placed Resident 1 on the floor and continued CPR on the floor. During another phone interview on [DATE] at 3:35 PM with RN 1, RN 1 stated that on [DATE] when Resident 1 was found unresponsive, she searched for Resident 1's code status and could not find it. RN 1 stated that when there is a resident that's unresponsive and pulseless, the facility staff must first search for the resident's code status because if the resident's code status is a DNR (Do not Resuscitate, allow natural death), they would not have to initiate code blue. During another phone interview on [DATE] at 3:44 PM with CNA 1, CNA 1 stated that when she found Resident 1 unresponsive on [DATE] at around 3:, she did not check Resident 1's pulse or respirations. CNA 1 stated she did not call for help by shouting code blue. CNA 1 added she did not initiate CPR. During a phone interview on [DATE] at 4:16 PM with EMS Crew, Paramedic (PC) 1, PC 1 stated that on [DATE], PC 1 and PC 2 responded to the facility's call to 911 (a phone number used to contact the emergency services) emergency services for a resident that was unresponsive. PC 1 stated that on [DATE] upon arriving in Resident 1's room, PC 1 stated the he observed Resident 1 on the bed and two facility staff members (unable to state the names and titles) were next to Resident 1, and one of the facility staff members (unable to state name and title) was performing CPR. PC 1 stated Resident 1 was wearing a non-rebreather mask and staff were not using an Ambu-bag. PC 1 stated that an oxygen mask like the non-rebreather mask was not an appropriate equipment to use while conducting a CPR. PC 1 stated that the Ambu-bag was observed right next to Resident 1's head of the bed but was not being used by the facility staff because PC 1 observed that it was not inflated (be filled or expanded with air) and not connected to an oxygen source. PC 1 also stated that the EMS crew had to move Resident 1 from the bed to the floor because Resident 1 was not placed under a backboard while on the bed. PC 1 stated that the EMS crew continued to perform CPR on Resident 1 for about 15 more minutes. During a phone interview on [DATE] at 4:43 PM with another EMS Crew, PC 2, PC 2 stated that on [DATE] when the EMS crew responded to the facility's 911 call, PC 2 observed one facility staff member (unable to state the name and title) perform CPR on Resident 1. PC 2 stated that the facility staff member was not performing adequate CPR because the rate was inconsistent and slow and described the facility staff's compressions as it would stop and go and stop. PC 2 further stated that during his observation, the facility staff member performing the CPR was only using one hand, instead of two hands during chest compressions. PC 2 stated that the facility staff performing the CPR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 16 of 36 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 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 was not using the Ambu-bag to provide rescue breaths because Resident 1 was placed on a non-breather mask. PC 2 further stated that the facility staff did not place Resident 1 on a backboard and performed CPR on the bed. During a review of an SOD titled, Declaration, signed by LVN 5, dated [DATE], the SOD indicated that on [DATE] at around 3:15 PM, LVN 5 heard CNA 1 informing LVN 2 that Resident 1 was unresponsive. The SOD indicated that LVN 5 observed LVN 2 ran towards [Nursing] Station 1. The SOD indicated that LVN 5 assessed Resident 1 and the resident looked pale, unresponsive, and pulseless. The SOD indicated that LVN 5 recalled how LVN 2 searched for Resident 1's code status in the resident's electronic records and could not find Resident 1's code status. The SOD indicated that LVN 5 recalled that LVN 2 asked the facility's Social Worker (SW 2) regarding Resident 1's code status, and SW 2 stated that Resident 1's code status was full code and started CPR. During an interview on [DATE] at 9:37 AM, LVN 5 stated that on [DATE] at around 3 PM, she heard CNA 1 informed LVN 2 that Resident 1 was unresponsive. LVN 5 stated she instructed LVN 2 to get the EC, however, LVN 2 went to Nursing Station 1. LVN 5 stated she assessed Resident 1 and the resident was unresponsive, pale, and pulseless. LVN 5 stated that LVN 1, RN 2, and SW 2 were inside Resident 1's room. LVN 5 stated she went out of Resident 1's room to search for Resident 1's code status in the resident's physical chart. LVN 5 stated she needed to know Resident 1's code status before starting CPR. During an interview on [DATE] at 10:24 AM with LVN 5, LVN 5 stated that if a resident is unresponsive and pulseless, staff must make sure that the resident is a full code before initiating CPR. LVN 5 added that the chest compression rate for an effective CPR is 30 compressions per minute. LVN 5 also added that a non-rebreather mask may also be used during CPR. ? During a phone interview on [DATE] at 10:29 AM with CNA 2, CNA 2 stated that on [DATE], he participated in performing CPR on Resident 1. CNA 2 stated he performed CPR at 80 compressions per minute because Resident 1 was fragile. CNA 2 stated that when the EMS arrived, CNA 2 and another LVN (LVN 2) were performing CPR on Resident 1 while the resident was on the bed. CNA 2 stated that he could not remember if an Ambu-bag was used on Resident 1. CNA 2 also stated that he could not recall if a backboard was placed under Resident 1. During an interview on [DATE] at 10:45 AM with 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 stated that RN 1 instructed the nurses to perform CPR on Resident 1. During an interview on [DATE] 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 17 of 36 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 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] 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] Event ID: Facility ID: 056190 If continuation sheet Page 18 of 36 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 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 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of two sampled residents (Resident 1) diagnosed of respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult) and recurrent pneumonia (an infection/inflammation in the lungs) by failing to: 1. Administer respiratory medications consistently as ordered for Resident 1 for COPD, chest congestion and shortness of breath. The Medication Administration Record (MAR) indicated the following missed respiratory treatments: -Acetylcysteine Inhalation Solution 20% (a medication used to thin mucus in the lungs) 25 (twenty-five) scheduled times between [DATE] to [DATE]. -Budenoside Inhalation Suspension (a medication inhaled to reduce swelling in the airways) 31 (thirty-one) scheduled times between [DATE] to [DATE]. -Ipratropium-albuterol Inhalation Solution (a medication used in a nebulizer that combines two drugs to relax and open the airways) 60 (sixty) scheduled times between [DATE] to [DATE]. 2. Monitor Resident 1 for respiratory distress (life-threatening condition that causes severe difficulty breathing. It occurs when the lungs become inflamed and damaged, making it difficult for oxygen to reach the bloodstream) and change in respiratory condition, in accordance with the resident's care plan for COPD and emphysema when Nurse Practitioner (NP) 1 identified Resident 1 on [DATE] as having cough, congestion, abnormal lung sounds and respiratory distress with oxygen saturation of 93% at 3 liter of oxygen and Registered Nurse (RN) 5 received abnormal laboratory (lab) and chest Xray (CXR - (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results on [DATE]. 3. Revise and implement Resident 1's care plan to assess or monitor Resident 1's respiratory status that included assessment of lung sounds and monitoring Resident 1's worsening cough and congestion to initiate nursing interventions, after receiving Resident 1's abnormal laboratory (lab) and CXR results on [DATE]. 4. Notify Medical Doctor (MD) 1 of Resident 1's elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count and abnormal chest x-ray results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. This deficient practice had the potential to result to medical and respiratory complications which included severe respiratory distress/failure, collapsed lungs, septicemia that may lead to hospitalization and/or death. Furthermore, these deficient practices delayed necessary medical evaluation and treatment of Resident 1's respiratory condition from [DATE] to [DATE]. On [DATE], Resident 1 was found unresponsive and pulseless at 3:05 PM. Cardiopulmonary Resuscitation (CPR) was performed and Resident 1 was later pronounced dead on [DATE] at 3:48 PM by Emergency Medical Services (EMS). Cross referenced to F678Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including COPD, emphysema, respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), recurrent pneumonia (an infection/inflammation in the lungs) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a review of Residents Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 19 of 36 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 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 1's Minimum Data Sheet (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's Medication Administration Record (MAR) for the months of [DATE], [DATE], and [DATE], the MAR indicated the following orders: 1. Acetylcysteine Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, start date [DATE]. 2. Budenoside Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD, start date [DATE]. 3. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment, start date [DATE]. During a continued review of resident 1's MAR for the months of [DATE], [DATE], and [DATE] indicated no documentation on the following days and times for Resident 1's Acetylcysteine Inhalation Solution: [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 9AM and 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM,[DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 9AM and 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, and [DATE] at 9 AM. The MAR for [DATE], [DATE], and [DATE] indicated a total of 25 undocumented administrations for Acetylcysteine between [DATE] and [DATE]. During a continued review of Resident 1's MAR for the months of [DATE] to [DATE] indicated no documentation on the following days and time for Resident 1's Budenoside Inhalation Suspension: [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9AM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9AM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, and [DATE] at 9 AM . The MAR for [DATE] to [DATE] indicated a total of 31 undocumented administrations for Budenoside between [DATE] and [DATE]. During a continued review of Resident 1's MAR for the months of [DATE] to [DATE] indicated no documentation on the following days and time for Resident 1's Ipratropium-Albuterol Inhalation Solution: [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM; [DATE] at 9 AM, 12 PM, 5 PM and 9 PM; [DATE] at 5 PM and 9 PM; [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM; [DATE] at 12 PM, 5 PM, and 9 PM; [DATE] at 9 AM, 12 PM, 5 PM, and 9 PM; [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 12 PM, [DATE] at 9 AM and 12 PM, and [DATE] at 12 PM. The MAR for [DATE] to [DATE] indicated a total of 60 undocumented administrations for Resident 1's Ipratropium-Albuterol between September and [DATE]. During a review of Resident 1's physician Progress Notes (PN) dated [DATE], authored by Nurse Practitioner (NP) 1, the PN indicated Resident 1 had diminished breath sounds, was on three liters of oxygen, no respiratory distress, and with a nonproductive cough at the time of the exam. Rales (crackling sounds in the lungs caused by air moving through fluid) and rhonchi (low, snoring-like lung sounds caused by air moving through mucus in larger airways) noted on respiratory exam. The PN further indicated, Plan is to continue regular breathing treatments as scheduled. During another review of Resident 1's PN dated [DATE], authored by Licensed Vocational Nurse (LVN) 8, the PN indicated, shortness of breath noted. Nurse observed shortness of breath (upon exertion). Right lung clear. Left lung clear. Oxygen via nasal cannula (a small plastic tube, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 20 of 36 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 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 fits into the person's nostrils for providing supplemental oxygen). During a review of Resident 1's physician PN dated [DATE] and authored by Medical Doctor (MD) 3, the PN indicated, Rhonchi present, diminished lung sounds. During another review of Resident 1's PN dated [DATE], authored by Registered Nurse (RN) 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated [DATE], authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated [DATE], authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During a review of Resident 1's physician PN dated [DATE] and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a review of Resident 1's physician Progress Notes dated [DATE], authored by NP 1, the note indicated NP 1 assessed Resident 1's medical condition at the facility. The note further indicated Resident 1's lung exam exhibited rales (abnormal crackling sounds in the lungs when breathing). The note indicated Resident 1 was on oxygen at 3 liters per minute (LPM- a unit measuring the flow rate of oxygen through a delivery device) with an oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage [normal for COPD is 88% to 92%]) level of 93%, with respiratory distress noted, and coughing. The note indicated to continue regular breathing treatments as scheduled, chest percussion therapy (CPT- a technique that uses rhythmic clapping on the chest and back to loosen and clear mucus from the lungs) two times a day with Mucomyst (Acetylcysteine- a medication used to thin mucus in the lungs), wean off of oxygen, chest x-ray, and labs that included CBC (complete blood count) and CMP (comprehensive metabolic panel) to rule out infection etiology. During a review of Resident 1's Orders Report for [DATE], the Report indicated the following physician orders: 1. Chest x-ray 2 view due to congestion and cough, ordered on [DATE] by MD 1 at 3:50 PM as confirmed by RN 5 2. CBC and CMP due to congestion and cough, ordered on [DATE] by MD 1 at 4:01 PM as confirmed by RN 5 3. Acetylcysteine Inhalation Solution 20% 3 mL (milliliter- a measure of volume) inhale orally two times a day for cough, CPT with [Acetylcysteine] 3 mL 20% solution, ordered on [DATE] by MD 1 at 4:17 PM as confirmed by RN 5 During a review of Resident 1's lab results dated [DATE], the results indicated WBC of 16.85 x10*3/ul (Normal range 4.0-11.0 x10*3/ul). The lab results indicated a collected date of [DATE] at 8:10 AM and a result date of [DATE] at 12:59 PM, faxed to the facility on [DATE] at 1:10 PM. During a review of Resident 1's Final X-ray report dated [DATE], the report indicated mild patchy opacity (an area that appears white or dense on an x-ray) in left lower lung represent infectious process and a suggestion for radiographic follow-up examination to look for resolution, faxed to the facility on [DATE] at 11:13 PM. During a review of RN 5's text messages (a standard for sending short, text-only messages between mobile phones) thread to NP 1 on [DATE] at 1:52 PM from the facility's cellular phone, the text thread indicated pictures of Resident 1's faxed lab results for the CBC and CMP drawn on [DATE] and the faxed chest x-ray results from [DATE]. The text messages did not indicate a confirmation of text message delivery or a text response from NP 1. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On [DATE] timed at 10:36 PM, and signed by RN 5, the note indicated NP 1 came to see Resident 1 and ordered chest x-ray for congestion and cough, CBC and CMP for congestion and cough, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 21 of 36 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 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 Acetylcysteine Inhalation Solution 20% 3mL inhale orally two times a day for cough, and CPT two times a day with Acetylcysteine. 2. On?[DATE],?timed at 4:10 PM,?and?signed?by?RN?1,?the?note?indicated?that at 3:15 PM,?the charge nurse?reported to [RN 1] that?she saw [Resident 1] during rounds unresponsive.?The?note further?indicated?that RN 1?went to the room to assess Resident 1 and?could not?obtain the resident's blood pressure. The?note?also?indicated?that RN 1 instructed one of the team members to start CPR right away. The?note?indicated?that CPR was continued until the?Emergency Medical Services (EMS?-?a system that provides emergency medical care) crew from the local Fire Department (FD)?arrived?at 3:29 PM. The entry further?indicated?that?the resident was pronounced deceased at 3:48 PM.? The progress notes did not indicate MD 1 or NP 1 verbally confirmed receipt of Resident 1's abnormal and chest x-ray with left lung opacity, or that the results were discussed with Resident 1's providers by any licensed nurses. The progress notes also did not indicate a change in condition (CIC/SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) or assessment and monitoring by licensed nurses for cough and congestion after NP 1 ordered CBC, CMP, chest x-ray, and CPT with Acetylcysteine for Resident 1's cough and congestion. The PN also did not indicate a CIC/SBAR with assessment and monitoring for Resident 1's WBC 16.85 x10*3/ul and chest x-ray with left lung opacity. During a review of Resident 1's CP initiated on [DATE] and revised [DATE], the CP indicated Resident 1 had impaired gas exchange related to COPD. The CP indicated a goal for Resident 1 to maintain O2 sat within personal goal range. The CP indicated interventions to evaluate capillary refill, evaluate for change in level of consciousness, evaluate for restlessness, evaluate for use of accessory muscles while breathing, evaluate mental status, evaluate respiratory rate and effort, evaluate skin color, temperature and characteristics, monitor for changes in respiratory rate or shallow breathing, and monitor for use of accessory muscles. During another review of Resident 1's CP initiated on [DATE] and revised [DATE], the CP indicated Resident 1 had oxygen therapy related to respiratory illness. The CP indicated goals for Resident 1 not to have signs and symptoms of poor oxygen absorption. The CP also indicated to monitor for signs and symptoms of respiratory distress and report to the MD as needed: respirations, O2 sat, increased heart rate, restlessness, sweating, headaches, lethargy, confusion, atelectasis (partial or complete lung collapse), hemoptysis (coughing blood), cough, painful breathing, accessory muscle usage, and skin color. During further review of Resident 1's current care plans, the CPs did not include a revised/updated care plan for Resident 1's new onset or worsening cough and congestion that included at risk for infection related to the abnormally high WBC lab results and abnormal chest x-ray received on [DATE]. During an interview with RN 5 on [DATE] at 11:08 AM, RN 5 stated that Resident 1's lab and diagnostic results were faxed to the facility on [DATE], and the results were reviewed by the RN on shift. The RN was responsible for sending lab and diagnostic results to the MD and obtaining new orders. During the same interview with RN 5, RN 5 stated she was aware NP 1 came to facility on [DATE] and placed new orders for Resident 1 that included CBC, CMP, chest x-ray, and CPT with Acetylcysteine for Resident 1's worsening cough and congestion. RN 5 further stated that these new orders should have triggered her to initiate a CIC/SBAR and assess Resident 1's respiratory condition because it was a change in the resident's condition, but RN 5 stated that she did not initiate a CIC/SBAR to assess/monitor Resident 1's respiratory condition such as lung sounds or breathing to ensure Resident 1 was not in respiratory distress or experiencing shortness of breath. During another interview with RN 5 on [DATE] at 4:54 PM, RN 5 stated that when she received Resident 1's lab and x-ray results on [DATE] at 1:52 PM, RN 5 sent pictures of the lab and CXR result to NP 1's cellular phone but never received text message responses back from NP 1. RN 5 further stated that she also faxed Resident 1's lab and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 22 of 36 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 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 CXR results to MD 1's office on [DATE], but did not verify the lab results were received by MD 1's office. RN 5 stated she did not call MD1's office or NP 1's cellular phone to confirm receipt of Resident 1's lab and CXR results. RN 5 stated that she should have called MD 1's office or NP 1 to verify the receipt of Resident 1's lab and CXR results. RN 5 stated that elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities indicated an infectious process and not relaying the results to MD 1 or NP 1 delayed the provider's from providing orders to treat Resident 1's respiratory infection. During the same interview with RN 5 [DATE] at 4:54 PM, RN 5 stated that she should have also initiated a CIC/SBAR on [DATE] for Resident 1's elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities and assessed Resident 1 for signs of respiratory distress or shortness of breath, but she did not. During a concurrent record review and interview with RN 5 on [DATE] at 4:54 PM, Resident 1's Progress Notes for [DATE] was reviewed. RN 5 stated she did not document that she notified MD 1 or NP 1 of Resident 1's abnormal lab results indicating elevated WBC and abnormal CXR. RN 5 stated that there was no documentation in the progress notes of any licensed nurses discussing the WBC or chest x-ray results with NP 1 or MD 1. RN 5 also stated there was no documentation of a CIC/SBAR or assessment and monitoring by licensed nurses for cough and congestion after [DATE] after NP 1 ordered CBC, CMP, CXR, and CPT with Acetylcysteine for Resident 1's cough and congestion in the progress notes. RN 5 also stated the progress notes did not contain documentation of a CIC/SBAR with assessment and monitoring for Resident 1's WBC of 16.85 x10*3/ul and CXR with left lung opacity. During an interview with MD 1 on [DATE] at 11:23 AM, MD 1 stated that Resident 1's WBC of 16.85 x10*3/ul and chest x-ray results with left lung opacities were not received by her office. MD 1 also stated that the facility did not have NP 1 or MD 1's direct cellphone numbers, thereby making it impossible for any residents' results to be received via text message. MD 1 further stated the facility's nurses had a practice of documenting lab and diagnostic results were faxed to her office, even if the lab and diagnostic results were not confirmed as received. MD 1 elaborated that the facility's nurses would document physician notified without actual notification. MD 1 stated that the facility's nurses should have called her practice to verify receipt of lab and diagnostic results. During an interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated she was familiar with Resident 1. RN 3 stated the text messages to NP 1 would not work because the number used was actually the direct line to MD 1's operator and would not be able to receive text messages. RN 3 stated that Resident 1's lab and CXR results should have been faxed to MD 1's office, with verbal confirmation from MD1's office staff by phone. During the same interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated that abnormal lab results were considered a change in a resident's condition. RN 3 further explained that there were two missed opportunities for RN 5 to initiate a CIC/SBAR and conduct an assessment of Resident 1: 1. When RN 5 received NP 1's orders of labs, chest-x-ray and new respiratory treatments for Resident 1's chest congestion and cough 2. When RN 5 received Resident 1's results indicating elevated WBCs of 16.85 x10*3/ul and chest x-ray with left lung opacities, RN 3 stated Resident 1 should have been assessed for shortness of breath or difficulty breathing so that staff can properly intervene if the resident was in respiratory distress. By not doing so, Resident 1 could die from respiratory complications. During an interview with the Director of Nursing (DON) on [DATE] at 11:41 AM, the DON further stated that nurses were expected to perform a full head-to-toe assessment when residents experience a change in condition. The DON stated this was important to fully understand the resident's clinical status and what interventions needed to be done. The DON stated that, by failing to properly assess Resident 1 and initiate a CIC/SBAR for continued assessment and monitoring of Resident 1's respiratory status, the resident was at risk for further decline. During an interview with MD 2 on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 23 of 36 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 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] at 5:57 PM, Resident 1's MAR for September to [DATE] 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] 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], the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe. Event ID: Facility ID: 056190 If continuation sheet Page 24 of 36 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 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four out of five facility staff members, Registered Nurses (RNs)?1 and 2, and Certified Nursing Assistants (CNAs)?1 and 2, demonstrated competencies and skill sets necessary to provide emergency response and perform cardiopulmonary resuscitation (CPR-CPR is an emergency, life?saving procedure performed when the heart stops beating and involves chest compressions at a rate of 100-120?beats per minute (bpm) and rescue breaths to maintain blood flow and oxygenation) as indicated in the facilities policy and procedure (PP) for Emergency Procedure - Cardiopulmonary Resuscitation and the American Red Cross CPR guidance as evidence by: 1. CNA 1 stated it took two (2) minutes to check for an unresponsive resident's pulse and breathing prior to performing CPR. 2.CNA 2 stated it took thirty (30) seconds to check for an unresponsive resident's pulse and breathing prior to performing CPR. 3.CNA 1 and CNA 2 failed to indicate the correct chest compressions at a rate of 100 - 120 bpm. 4. Registered Nurse (RN) 1 failed to demonstrate how to set up, turn it on, and check if the portable suction device (machine used to pull liquids away from the mouth or throat) and emergency oxygen tank (portable metal cylinder containing compressed oxygen) was operable as part of the emergency equipment in accordance with the facility's PP titled Disposable Suction Canister. 5. Registered Nurse (RN) 1 and RN 2 failed to identify the location of the emergency supplies in the emergency crash cart such as the adult oxygen masks (medical device that fits over the nose and mouth to deliver oxygen from the oxygen tank to the lungs), suction catheters (thin flexible tube connected to a portable suction device to remove fluids from the resident's mouth or throat), short and long connective tubing for the suction machine, and the CPR mask/shield (small plastic barrier to deliver safe recuse breaths to an unresponsive resident) in accordance with the facility's PP Suctioning the Upper Airway, 6. RN 1 failed to state the correct chest compression rate of 100-120 bpm and the depth of compressions at 2 inches or 5 centimeters. 7. Director of Staff Development (DSD) failed to demonstrate proficient chest compressions at a rate of 100 - 120 bpm. 8. The facility failed to evaluate the competency and skills set of RNs 1 and 2 and CNs 1 and 2 to determine the understanding and compliance of the Licensed Nurses (LNs) or CNAs with CPR to training provided during these Mock Code Blue (life threatening emergencies that require immediate CPR) Drills. These deficient practices had the potential to result in ineffective and poor-quality CPR and emergency response, which may lead to rib fractures (broken bone), irreversible brain damage due to prolonged lack of oxygen, and ultimately preventable death. Findings: During a concurrent observation and interview on [DATE] at 3:36 PM, CNA 1was asked to demonstration CPR skills as instructed during the Mock Code Blue Drill held on [DATE]. CNA 1 stated, if a resident was found unresponsive, he would check the resident's chest rise and pulse on the neck for two (2) minutes before initiating chest compressions. CNA 1 stated, he did not know the correct rate of the chest compressions, but he sings happy birthday slowly while performing chest compressions. During a concurrent observation and interview on [DATE] at 4PM with CNA 2, CNA 2 was asked to demonstrate how to perform CPR as instructed during the Mock Code Blue Drill held in [DATE]. CNA 2 was observed pressing two fingers to check the carotid pulse on the right side of her neck and then performed chest compressions. CNA 2 stated, if a resident was found unresponsive, she needed to check if the resident had chest rise and a pulse for thirty (30) seconds. CNA 2 stated, she was not sure how fast the compressions should be, but she just needed to count fast. During a concurrent observation and interview on [DATE] at 4:32 PM with RN 1 in front of the emergency crash cart, RN 1 was observed checking the emergency crash cart using the Emergency Cart Checklist document. RN 1 stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 25 of 36 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 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she has not checked the emergency crash cart for today. RN 1 was asked to demonstrate how to operate the suction machine and oxygen tank and the emergency equipment in the emergency cart. During the interview, RN 1 stated: 1.She he did not know where the adult oxygen masks, suction catheters, short and long connective tubing for the suction catheters, and the CPR mask/shield were located. 2. She did not know where the personal protective equipment (PPE) was located in the emergency cart. 3. She did not know how to connect, turn on, and check if the suction machine was operable and found the [NAME] suction tip (a rigid plastic medical device used to clear fluids from the mouth or throat) not connected to the machine. 4. She did not know how to check if the oxygen tank was operable or contained oxygen. During the same observation and interview on [DATE] at 4:40 PM with RN 1 in front of the emergency crash cart, RN 1 stated she did not know what pressure the suction machine should be set at. RN 1 stated, it was important to be familiar with the emergency crash cart to ensure all equipment was operable in case of emergency because it can make a difference in a life-or-death situation. During an observation and interview on [DATE] at 4:50 PM with RN 1 was asked to demonstrate how to perform CPR as instructed during the in-service and the Mock Code Blue Drill held on [DATE]. RN 1 stated the rate of compressions for CPR was 100 - 110 bpm and the compression depth was 1/3 of the chest. RN 1 stated, the facility conducts weekly mock Code Blue Drills where all the LNs and CNAs were required to participate by demonstrating how to perform chest compressions, verbally answer knowledge- based and scenario-based questions related to CPR, and signing the in-service sign-in sheet. RN 1 stated, there was no documentation to indicate the staffs were evaluated for competencies, understanding and the effectiveness of the mock Code Blue Drills for the LNs and CNAs. During an interview on [DATE] at 9:30 AM, with the Director of Staff Development (DSD), the DSD stated that during the facility's Mock Code Blue Drills, each licensed nurse (LN) and CNA demonstrated CPR by performing thirty (30) chest compressions to two (2) breaths using an ambu-bag (a handheld portable device used to manually deliver oxygen into the lungs) for two (2) minutes. During the same observation and interview on [DATE] at 9:45 AM with the DSD, the DSD was asked to demonstrate how to perform CPR as instructed during the in-service and Mock Code Blue Drill held in [DATE]. The DSD was observed with her bilateral arms straight, elbows locked, and hands on top of each other and interacted together performing chest compressions on top of the overbed side table. The DSD stated the chest compression count rate per beat was 1 one thousand, 2 one thousand, 3 one thousand, 4 one thousand until 30 one thousand. During the same interview on [DATE] at 10 AM with the DSD, the Director of Staff Development (DSD) stated that Registered Nurses (RNs) are the primary point of contact during any Code Blue situation and they are expected to know the location of emergency supplies in the crash cart and ensure that all emergency equipment is operable at each shift. During a concurrent observation and interview on [DATE] at 11:56 AM, in front of the emergency crash cart, RN 2 was observed checking the crash cart using the facility's Emergency Cart Checklist document. RN 2 did not know the location of the suction catheters and CPR masks/shields within the crash cart. During the interview, RN 2 stated it was important to check if the equipment was operable and to know the location of emergency equipment because it can be time-consuming looking for equipment. RN 2 further stated that the portable suction device should be set at a negative pressure of 200-300 millimeters of mercury (mmHg). During a concurrent interview and record review on [DATE] at 4:30 PM, during an interview with the Director of Staff Development (DSD) and review of the facility's ETP Attendance Roster (Single Day) dated [DATE], the DSD stated she monitored the effectiveness of the mock Code Blue Drills through staff verbal responses, return demonstrations, and participation as evidenced by the in-service sign-in roster. The DSD further stated there was no documented evidence the competencies and understanding of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 26 of 36 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 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Licensed Nurses (LNs) and CNAs were evaluated for the training provided during these Mock Code Blue Drills as of [DATE]. During a review of the facility's P&P titled Suctioning the Upper Airway, dated [DATE], the P&P indicated that the portable suction device should have a negative pressure set at 10-15mmHg. During a review of the instruction manual for Disposable Suction Canister, date unknown, the manual indicated to attach the suction cannister's short vacuum tubing to the suction machine to one open port, attach the long vacuuming tubing to the second open port, and ensure all seals are intact by turning on the vacuum pump. During a review of the facility's policy and procedures (P&P) titled Emergency Procedure Cardiopulmonary Resuscitation, dated February 2018, the P&P indicated chest compressions are performed by pushing hard to a depth of at least 2 inches (5 centimeters) at a rate of at least 100 compressions per minute. During a review of the facility's P&P title Competency of Nursing Staff, dated [DATE], the P&P indicated: 1. All the licensed nurses and nursing assistants employed by the facility will demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessment. 2. The factors considered in the creation of the competency-based staff development and training program include a method to track, assess, plan, implement, and evaluate the effectiveness of training. 3. The competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by the staff already deemed competent in that skill or knowledge. 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. Event ID: Facility ID: 056190 If continuation sheet Page 27 of 36 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 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 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of two sampled residents (Resident 1). Licensed nurses did not administer prescribed respiratory medications to Resident 1, who had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing breathing difficulty) and was oxygen-dependent. Missed doses included: Acetylcysteine Inhalation Solution 20% (used to thin mucus in the lungs): 25 scheduled doses between September and November 2025 Budesonide Inhalation Suspension (reduces airway inflammation): 31 scheduled doses between September and November 2025 Ipratropium-Albuterol Inhalation Solution (relaxes and opens airways): 60 scheduled doses between September and November 2025 This failure placed Resident 1 at risk for respiratory compromise and deterioration related to COPD exacerbation, potentially resulting in further complications and hospitalization. Cross referenced to F678 Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including COPD, emphysema, respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), recurrent pneumonia (an infection/inflammation in the lungs) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/6/2025, the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's Care Plan (CP) initiated on 4/11/2025 at revised 11/18/2025, the CP indicated Resident 1 had impaired gas exchange related to ineffective airway clearance, dyspnea (difficulty breathing)/ shortness of breath (SOB), COPD, and emphysema. The CP further indicated interventions to administer medications as ordered. During a review of Resident 1's Medication Administration Record (MAR) for the months of September, October, and November 2025, the MAR indicated the following orders: 1. Acetylcysteine Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, start date 9/30/2025. 2. Budenoside Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD, start date 3/3/2025. 3. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment, start date 6/16/2025. During a continued review of resident 1's MAR for the months of September, October, and November 2025 indicated no documentation on the following days and times for Resident 1's Acetylcysteine Inhalation Solution: 9/30/2025 at 6 PM, 10/1/2025 at 6 PM, 10/2/2025 at 6 PM, 10/3/2025 at 6 PM, 10/4/2025 at 6 PM, 10/5/2025 at 6 PM, 10/6/2025 at 6 PM, 10/7/2025 at 9AM and 6 PM, 10/8/2025 at 6 PM, 10/9/2025 at 6 PM, 10/11/2025 at 6 PM,10/12/2025 at 6 PM, 10/17/2025 at 6 PM, 10/18/2025 at 6 PM, 10/20/2025 at 6 PM, 10/23/2025 at 6 PM, 10/24/2025 at 6 PM, 10/25/2025 at 6 PM, 10/28/2025 at 9AM and 6 PM, 10/31/2025 at 6 PM, 11/1/2025 at 6 PM, 11/15/2025 at 6 PM, and 11/22/2025 at 9 AM. The MAR for September, October, and November 2025 indicated a total of 25 undocumented administrations for Acetylcysteine between September and November 2025. During a continued review of Resident 1's MAR for the months of September to November 2025 indicated no documentation on the following days and time for Resident 1's Budenoside Inhalation Suspension: 9/5/2025 at 9 PM, 9/30/2025 at 9 PM, 10/1/2025 at 9 PM, 10/2/2025 at 9 PM, 10/3/2025 at 9 PM, 10/4/2025 at 9 PM, 10/5/2025 at 9 PM, 10/6/20258 at 9 PM, 10/7/2025 at 9AM and 9 PM, 10/8/2025 at 9 PM, 10/9/2025 at 9 PM, 10/11/2025 at 9 PM, 10/12/2025 at 9 PM, 10/15/2025 at 9 PM, 10/17/2025 at 9 PM, 10/18/2025 at 9 PM, 10/20/2025 at 9 Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 28 of 36 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 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 PM, 10/22/2025 at 9 PM, 10/23/2025 at 9 PM, 10/24/2025 at 9 PM, 10/25/2025 at 9 PM, 10/28/2025 at 9AM and 9 PM, 10/31/2025 at 9 PM, 11/1/2025 at 9 PM, 11/6/2025 at 9 PM, 11/13/2025 at 9 PM, 11/14/2025 at 9 PM, 11/15/2025 at 9 PM, and 11/22/2025 at 9 AM. The MAR for September to November 2025 indicated a total of 31 undocumented administrations for Budenoside between September and November 2025. During a continued review of Resident 1's MAR for the months of September to November 2025 indicated no documentation on the following days and time for Resident 1's Ipratropium-Albuterol Inhalation Solution: 9/5/2025 at 5 PM and 9 PM, 9/30/2025 at 5 PM and 9 PM, 10/1/2025 at 5 PM and 9 PM, 10/2/2025 at 5 PM and 9 PM, 10/3/2025 at 5 PM and 9 PM, 10/4/2025 at 5 PM and 9 PM, 10/5/2025 at 5 PM and 9 PM, 10/6/2025 at 5 PM and 9 PM; 10/7/2025 at 9 AM, 12 PM, 5 PM and 9 PM; 10/8/2025 at 5 PM and 9 PM; 10/9/2025 at 5 PM and 9 PM, 10/11/2025 at 5 PM and 9 PM, 10/12/2025 at 5 PM and 9 PM, 10/15/2025 at 9PM, 10/17/2025 at 5 PM and 9 PM, 10/18/2025 at 5 PM and 9 PM, 10/20/2025 at 5 PM and 9 PM, 10/22/2025 at 9 PM, 10/23/2025 at 5 PM and 9 PM, 10/24/2025 at 5 PM and 9 PM; 10/25/2025 at 12 PM, 5 PM, and 9 PM; 10/28/2025 at 9 AM, 12 PM, 5 PM, and 9 PM; 10/31/2025 at 5 PM and 9 PM, 11/1/2025 at 5 PM and 9 PM, 11/6/2025 at 9 PM, 11/13/2025 at 9 PM, 11/14/2025 at 9 PM, 11/15/2025 at 5 PM and 9 PM, 11/19/2025 at 12 PM, 11/22/2025 at 9 AM and 12 PM, and 11/30/2025 at 12 PM. The MAR for September to November 2025 indicated a total of 60 undocumented administrations for Resident 1's Ipratropium-Albuterol between September and November 2025. During a review of Resident 1's physician PN dated 9/29/202, authored by Nurse Practitioner (NP) 1, the PN indicated Resident 1 had diminished breath sounds, was on three liters of oxygen, no respiratory distress, and with a nonproductive cough at the time of the exam. Rales (crackling sounds in the lungs caused by air moving through fluid) and rhonchi (low, snoring-like lung sounds caused by air moving through mucus in larger airways) noted on respiratory exam. The PN further indicated, Plan is to continue regular breathing treatments as scheduled. During another review of Resident 1's physician PN dated 10/10/2025 and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During another review of Resident 1's PN dated 10/11/2025, authored by Licensed Vocational Nurse (LVN) 8, the PN indicated, shortness of breath noted. Nurse observed shortness of breath (upon exertion). Right lung clear. Left lung clear. Oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) During a review of Resident 1's physician PN dated 10/31/2025 and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a review of Resident 1's physician PN dated 11/8/2025 and authored by Medical Doctor (MD) 3, the PN indicated, Rhonchi present, diminished lung sounds. During another review of Resident 1's PN dated 11/9/2025, authored by Registered Nurse (RN) 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated 11/15/2025, authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated 11/17/2025, authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During a review of Resident 1's physician PN dated 11/30/2025 and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a concurrent interview and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 29 of 36 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 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. 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: 056190 If continuation sheet Page 30 of 36 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 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 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to verify received or follow up with the attending physician (Medical Doctor [MD] 1) and/or the Nurse Practitioner (NP) 1 of the abnormal laboratory and diagnostic results for one of two sampled residents (Resident 1) with abnormal laboratory and diagnostic results. Resident 1 had an elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count of 16.85 x10*3/ul (thousands of cells per microliter- a unit of measurement [Normal range 4.0-11.0 x10*3/ul]) and abnormal chest x-ray (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. This failure resulted in Resident 1 not to receive necessary medical intervention such as prescribing antibiotics (medication used to treat infection) which placed Resident 1 at risk for worsening infection, respiratory distress, sepsis (a life-threatening blood infection), hospitalization, and death. Cross referenced to F695 and F678 Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult), respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), recurrent pneumonia (an infection/inflammation in the lungs) and aneurysm of specified arteries (localized bulge on the wall of the blood vessels which pose a risk for rupture). During a review of Residents 1's Minimum Data Sheet (MDSa resident assessment tool) dated [DATE], the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 21's Care Plan, initiated on [DATE] and revised [DATE], indicated Resident 1 had impaired gas exchange. The intervention included to monitor and report any respiratory distress to the MD. During a review of Resident 1's MD Progress Notes (PN) dated [DATE], the notes indicated Resident 1 was assessed by Nurse Practitioner (NP) 1. The PN indicated Resident 1's lung exam exhibited rales (abnormal crackling sounds in the lungs when breathing) with respiratory distress, coughing and with oxygen saturation of 93% (normal range 90-100%) while receiving 3 L/min (liters per minute- a unit measuring the flow rate of oxygen through a delivery device). The PN indicated to continue regular breathing treatments as scheduled, physical therapy, chest percussion therapy (CPT- a technique that uses rhythmic clapping on the chest and back to loosen and clear mucus from the lungs) two times a day with administration of Mucomyst (acetylcysteine- a medication used to thin or loosen up mucus in the lungs), wean off of oxygen, obtain chest x-ray, and labs that included CBC (complete blood count) and CMP (comprehensive metabolic panel) to rule out possible cause of infection. During a review of Resident 1's Orders Report (a physician's order by MD 1) dated [DATE] indicated to obtain CBC and CMP, and Chest X-ray due to congestion and cough. During a review of Resident 1's lab results collected on [DATE] at 8:10 AM and resulted on[DATE] at 12:59 PM, faxed to the facility on [DATE] at 1:10 PM, indicated an (elevated) WBC 16.85 x10*3/ul (Normal range 4.0-11.0 x10*3/ul). During a review of Resident 1's Final chest X-ray report dated [DATE], the report indicated mild patchy opacity in left lower lung represent infectious process and a suggestion for radiographic follow-up examination to look for resolution, faxed to the facility on [DATE] at 11:13 PM. During a review of RN 5's text thread to NP 1 on (RN 5) [DATE] from the facility's RN Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 31 of 36 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 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 Supervisor (RN5) phone, the text thread indicated pictures of Resident 1's faxed lab results for the CBC and CMP drawn on [DATE] and the faxed chest x-ray results from [DATE]. The text thread did not indicate a confirmation of delivery or a response from NP 1. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: -On [DATE] timed at 10:36 PM, NP 1 came to see Resident 1 and ordered chest x-ray for congestion and cough, CBC and CMP for congestion and cough, and CPT two times a day with Acetylcysteine Inhalation Solution 20% in 3mL inhale orally two times a day -On?[DATE],?timed at 4:10 PM,?and?signed?by?RN?1,?the?note?indicated?that at 3:15 PM,?the Charge Nurse?reported to [RN 1] that?she saw the resident during rounds unresponsive, RN 1?assessed the resident and?could not?obtain the resident's blood pressure, RN 1 instructed one of the team members to start CPR right away which was continued until the?Emergency Medical Services (EMS?-?a system that provides emergency medical care) crew from the local Fire Department (FD)?arrived?at 3:29 PM. The PN indicated Resident 1 was pronounced deceased at 3:48 PM.? A review of Resident 1's PN indicated no evidence that a physician or NP were notified of Resident 1's abnormal lab or x-ray results and the abnormal WBC. The progress notes also did have a documented change in condition (CIC/SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) report or assessment related to Resident 1's WBC 16.85 x10*3/ul or chest x-ray with left lung opacity. During an interview with RN 5 on [DATE] at 11:08 AM, RN 5 stated lab and diagnostic results were faxed to the facility, and the results were reviewed by the RN on shift. The RN was responsible for sending lab and diagnostic results to the MD and obtaining new orders. RN 5 further explained that important results to send to the MD included opacities in a chest x-ray. During another interview with RN 5 on [DATE] at 4:54 PM, RN 5 stated that she sent Resident 1's lab and diagnostic results by text messages to NP 1 but did receive responses back from NP 1. RN 5 further stated that she also faxed Resident 1's results to MD 1's office but she did not verify or followed up with the physician if the lab results were received. RN 5 stated that elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities indicated an infectious process and not relaying the results delayed the providers from treating Resident 1's infection. During an interview with MD 1 on [DATE] at 11:23 AM, MD 1 stated that Resident 1's WBC of 16.85 x10*3/ul and chest x-ray results with left lung opacities were never received by faxed or text by her practice. MD 1 also stated that the facility did not have NP 1 or MD 1's cellphone numbers. thereby making it impossible for any residents' results to be received by text. MD 1 further stated the facility's nurses had a practice of documenting lab and diagnostic results were faxed to her practice, but the results were never received. MD 1 elaborated that the facility's nurses would document physician notified without actual notification. MD 1 stated that the facility's nurses should have called her practice to verify receipt of lab and diagnostic results. During an interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated the text messages to NP 1 would not work because the number used was actually the direct line to MD 1's operator and could not receive text messages. RN 3 stated that lab and diagnostic results should have been faxed to MD 1's practice, with verbal confirmation of receipt by phone. During an interview with the Director of Nursing (DON) on [DATE] at 11:41 AM, the DON stated that faxing residents' results to an MD was not enough; nurses were expected to call the MD and verify receipt of the results then document notification in a progress note with who the nurse spoke to, what results were discussed, and if any new orders were placed related to the results received. The DON further explained that Resident 1's WBC 16.85 x10*3/ul and chest x-ray with left lung opacity warranted a Change in Condition (CIC/SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) and therefore MD 1 should have been notified of the resident's change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 32 of 36 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 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] 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] 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], 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: 056190 If continuation sheet Page 33 of 36 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 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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult), respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), and recurrent pneumonia (an infection/inflammation in the lungs). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/6/2025, the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's care plan (CP) initiated on 4/11/2025 at revised on 11/18/2025, the CP indicated Resident 1 had an impaired gas exchange related to ineffective airway clearance, dyspnea (difficulty breathing), shortness of breath (SOB), COPD, and emphysema. The CP indicated goal for appropriate interventions that will improve airway function, maintain a patent airway, optimal oxygenation/ventilation, oxygen saturation (O2 sat- the percentage of oxygen in the blood) maintained greater than 92% (normal range for COPD: 88% - 92%), and mobilize secretions. The CP indicated interventions to administer medications as ordered. During a review of Resident 1's Medication Administration Record (MAR) for December 2025, the MAR indicated the following orders: 1. Order start dated 9/30/2025, the order indicated to administer Acetylcysteine (a medication used to thin mucus in the lungs) Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, 2. Order start dated 3/3/2025, the order indicated to administer Budenoside (a medication inhaled to reduce swelling in the airways) Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD. 3. Order start dated 6/16/2025, the order indicated to administer Ipratropium-Albuterol (a medication used in a nebulizer that combines two drugs to relax and open the airways) Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment. During a review of Resident 1's Medication Admin Audit Report dated December 2025, the report indicated the following: 1. Administration of Acetylcysteine Inhalation Solution 20% for COPD a. Schedule date: 12/5/2025 at 6 PM. Administration time: 12/5/2025 at 3:29 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:30 PM by LVN 9. b. Schedule date: 12/6/2025 at 6 PM. Administration time: 12/6/2025 at 3:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9. c. Schedule date: 12/11/2025 at 6 PM. Administration time: 12/10/2025 at 4:05 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 d. Schedule date: 12/12/2025 at 6 PM. Administration time: 12/12/2025 at 5:25 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 e. Schedule date: 12/13/2025 at 6 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 f. Schedule date: 12/19/2025 at 6 PM. Administration time: 12/19/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:09 PM by LVN 3 g. Schedule date: 12/23/2025 at 6 PM. Administration time: 12/23/2025 at 4:11 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 2. Administration of Budenoside Inhalation Suspension for COPD a. Schedule date: 12/4/2025 at 9 PM. Administration time: 12/4/2025 at 5:27 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:27 PM by LVN 9 b. Schedule date: 12/5/2025 at 9 PM. Administration time: 12/5/2025 at 5:33 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 34 of 36 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 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 Documented time in Resident 1's electronic records: 1/1/2026 at 3:34 PM by LVN 9 c. Schedule date: 12/6/2025 at 9 PM. Administration time: 12/6/2025 at 5:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9 d. Schedule date: 12/10/2025 at 9 PM. Administration time: 12/10/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:05 PM by LVN 3 e. Schedule date: 12/11/2025 at 9 PM. Administration time: 12/11/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 f. Schedule date: 12/12/2025 at 9 PM. Administration time: 12/10/2025 at 5:26 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 g. Schedule date: 12/13/2025 at 9 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 h. Schedule date: 12/18/2025 at 9 PM. Administration time: 12/18/2025 at 4:08 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:08 PM by LVN 3 i. Schedule date: 12/19/2025 at 9 PM. Administration time: 12/19/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:10 PM by LVN 3 j. Schedule date: 12/23/2025 at 9 PM. Administration time: 12/23/2025 at 4:12 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 3. Ipratropium-Albuterol Inhalation Solution a. Schedule date: 12/4/2025 at 9 PM. Administration time: 12/4/2025 at 3:27 PM. Documented time in Resident 1's electronic records in Resident 1's electronic records: 1/1/2026 at 3:27 PM by LVN 9 b. Schedule date: 12/5/2025 at 5 PM. Administration time: 12/5/2025 at 3:29 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:30 PM by LVN 9 c. Schedule date: 12/5/2025 at 9 PM. Administration time: 12/5/2025 at 3:34 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:34 PM by LVN 9 d. Schedule date: 12/6/2025 at 5 PM. Administration time: 12/6/2025 at 5:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9 e. Schedule date: 12/6/2025 at 9 PM. Administration time: 12/6/2025 at 3:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9 f. Schedule date: 12/10/2025 at 9 PM. Administration time: 12/10/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:05 PM by LVN 3 g. Schedule date: 12/11/2025 at 5 PM. Administration time: 12/10/2025 at 4:05 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 h. Schedule date: 12/11/2025 at 9 PM. Administration time: 12/11/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 i. Schedule date: 12/12/2025 at 5 PM. Administration time: 12/12/2025 at 5:25 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 j. Schedule date: 12/12/2025 at 9 PM. Administration time: 12/12/2025 at 5:26 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 k. Schedule date: 12/13/2025 at 5 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 l. Schedule date: 12/13/2025 at 9 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 m. Schedule date: 12/18/2025 at 9 PM. Administration time: 12/13/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:09 PM by LVN 3 n. Schedule date: 12/19/2025 at 5 PM. Administration time: 12/19/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:09 PM by LVN 3 o. Schedule date: 12/19/2025 at 9 PM. Administration time: 12/19/2025 at 4:10 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:10 PM by LVN 3 p. Schedule date: 12/23/2025 at 5 PM. Administration time: 12/23/2025 at 4:11 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 q. Schedule date: 12/23/2025 at 9 PM. Administration time: 12/23/2025 at 4:12 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 During an interview with LVN 9 on 1/2/2026 at 5:18 PM, LVN 9 stated she could not recall what days she worked for the month of December 2025 or what (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056190 If continuation sheet Page 35 of 36 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 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: 056190 If continuation sheet Page 36 of 36