Arlington Gardens Care Center: Fall Prevention Failures - CA
The director of nursing said it plainly: a sitter should have been assigned before the fourth fall. Resident 3, whose name was not released in inspection records, was on anticoagulant medication, a detail that matters because blood thinners make internal bleeding from a fall harder to stop and far more dangerous.
Inspectors from the Centers for Medicare and Medicaid Services visited the Riverside facility on August 27, 2025, following a complaint. What they found was a pattern of inaction documented in the facility's own records and confirmed by its own leadership.
The director of nursing told inspectors the facility had considered moving Resident 3 to a room closer to the nursing station after the falls began. There were no such rooms available, she said. Staff also discussed assigning a sitter, someone whose job is to stay with a high-risk resident and intervene before a fall happens. The facility chose not to do it. The reason the director of nursing gave: the facility wanted to be "less restrictive."
That reasoning applied even as the falls kept coming.
The monitoring that was in place, the director of nursing acknowledged, was standard two-hour rounding, the same check-in schedule used for every resident in the building. She told inspectors that given what was happening with Resident 3, that level of monitoring did not constitute an adequate intervention to prevent further falls.
Arlington Gardens had a falls protocol on the books. The policy, dated 2001, called for physicians to help identify fall history and risk factors, for staff to evaluate and document each fall, and for staff and physicians together to identify interventions to prevent the next one. The gap between what the protocol described and what happened with Resident 3 was what inspectors documented.
The facility's own director of nursing drew the same conclusion. She told inspectors that Resident 3 should have been rounded more frequently, and that a sitter should have been in place before he fell a fourth time.
CMS rated the harm level for this violation as minimal harm or potential for actual harm, and noted that few residents were affected. The classification reflects the regulatory framework inspectors use, not a judgment that nothing serious could have happened. The director of nursing's own words, that the possible outcomes included fracture or serious injury, describe something more than a near-miss on paper.
Anticoagulant medications are prescribed for conditions including atrial fibrillation, deep vein thrombosis, and mechanical heart valves. They reduce the blood's ability to clot. For a resident who falls repeatedly, that means a head injury that might be survivable for someone else can become a fatal bleed. A hip fracture that leads to surgery carries elevated risk of hemorrhage. The medication does not cause falls, but it changes what a fall can mean.
The decision to forgo a sitter in the name of being less restrictive is a judgment call nursing homes make. Sitters can feel intrusive. Constant supervision can affect a resident's sense of independence and dignity. Those are real considerations. They sit alongside the reality that Resident 3 was on blood thinners, had already fallen multiple times, and did not have a room near the nurses' station where staff could watch him more easily.
The director of nursing did not dispute what the record showed. She confirmed the falls, confirmed the absence of a sitter, confirmed the monitoring schedule that was in place, and confirmed that it was not enough.
Resident 3's outcome after the fourth fall is not described in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arlington Gardens Care Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
ARLINGTON GARDENS CARE CENTER in RIVERSIDE, CA was cited for violations during a health inspection on August 27, 2025.
The director of nursing said it plainly: a sitter should have been assigned before the fourth fall.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.