Arlington Gardens Care Center

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

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 grooming was provided when one resident (Resident 1) who was observed with long fingernails did not receive on-going grooming services.This failure had the potential for Resident 1 to be at risk for avoidable skin injuries.Findings:On August 25, 2025, an announced visit was conducted at the facility to investigate a complaint.On August 25, 2025, at 2:33 p.m., Resident 1 was interviewed. Resident 1 was alert, oriented, and well-dressed. Resident 1 was observed with long fingernails on her right hand and stated she would like to have her fingernails cut.On August 25, 2025, at 2:38 p.m., a concurrent observation, interview and record review was conducted with the treatment nurse. The Treatment Nurse (TN) was observed measuring Resident 1's fingernails on her right hand. The following measurements were observed, right index fingernail 1.6 cm (cm- centimeters

a unit of measurement), right middle fingernail 1.8 cm, right ring fingernail 1.9 cm, and right pinky fingernail 1.6 cm.The TN stated it is the responsibility of the TN and the certified nurse assistant (CNA) to care for residents' fingernails. The TN further stated Resident 1's long fingernails should have been addressed by

the TN and/or the CNA.On August 25, 2025, Resident 1's medical record was reviewed.The admission

record indicated Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses which included dementia (loss of intellectual functioning), hypertension (high blood pressure), acute kidney failure (decline if kidney function).The history and physical completed on January 31, 2025, indicated Resident 1 had no decision-making capacity.On August 27, 2025, at 2:11 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility policy on nail care is for the CNA, TN, and/or licensed nurses (LN) to conduct nailcare on a resident's fingernails during resident's care.

The DON stated the CNA, TN, and/or LN should have addressed Resident 1's nails during resident's routine care.A review of the facility policy and procedure titled Fingernails/Toenails, Care of, dated 2001, indicated .nail care includes daily cleaning and regular trimming.proper nail care can aid in the prevention of skin problems around the nail bed.trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Stop and report to the nurse supervisor.evidence of ingrown nails.pain.nails are too hard or too thick to cut with ease.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arlington Gardens Care Center

3688 Nye Avenue Riverside, CA 92505

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 0687

Provide appropriate foot 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 foot care was provided when one resident (Resident 1) who was observed with long toenails and did not receive on-going podiatry (foot care provided by a specialty doctor) care.This failure had the potential for Resident 1 to be at risk for avoidable skin injuries.Findings:On August 25, 2025, an announced visit was conducted at the facility to investigate a complaint.On August 25, 2025, at 2:33 p.m., Resident 1 was interviewed. Resident 1 was alert, oriented, and well-dressed. Resident 1 stated she had painful toenails.On August 25, 2025, at 2:38 p.m., a concurrent observation, interview and record review was conducted with the Treatment Nurse (TN).

Resident 1 was observed with long curved toenails on both feet. The TN was observed measuring Resident 1's toenails on her left foot. The following measurements were observed, left great toenail 2.0 cm (centimeters-a unit of measurement), left second toenail 0.7 cm, left third toenail 1.0 cm. Left fourth toenail 1.0 cm, and left pinky toenail 0.5 cm.The TN was further observed measuring Resident 1's toenails on her right foot. The following measurements were observed, right great toenail 2.5 cm, right second toenail 1.1 cm, right third toenail 1.0 cm, right fourth toenail 0.9 cm, and right pinky toenail 1.0 cm.The TN stated it is

the responsibility of the TN and the certified nurse assistant (CNA) to care for residents' toenails. The TN further stated the nursing staff should have informed podiatry of Resident 1's long toenails.On August 25, 2025, Resident 1's medical record was reviewed.The admission record indicated Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses which included dementia (loss of intellectual functioning), hypertension (high blood pressure), acute kidney failure (decline if kidney function).The history and physical completed on January 31, 2025, indicated Resident 1 had no decision-making capacity.The podiatry note dated April 10, 2025, indicated .Resident 1.onychomycosis (fungal infection toenails).dystrophic nails (abnormal nail shape, color, texture, or growth).paronychia (inflammation of skin surrounding toenail).with painful nail boarders.There was no documented evidence Resident 2 was seen by a podiatrist after April 10, 2025.On August 27, 2025, at 2:11 p.m., a concurrent interview and record review was conducted with

the Director of Nursing (DON). The DON stated the facility policy on nail care is for the CNA, TN, and/or licensed nurses (LN) to conduct nailcare on a resident during resident's routine care. The DON stated the CNA, TN, and/or LN should have scheduled podiatry services for Resident 1's toenails.A review of the facility policy and procedure titled Fingernails/Toenails, Care of, dated 2001, indicated .nail care includes daily cleaning and regular trimming.proper nail care can aid in the prevention of skin problems around the nail bed.trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Stop and report to the nurse supervisor.evidence of ingrown nails.pain.nails are too hard or too thick to cut with ease.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arlington Gardens Care Center

3688 Nye Avenue Riverside, CA 92505

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the resident and for the resident to be moved closer to the nursing station. The DON stated there were no rooms closer to the nurses' station and they did not assign a sitter because the facility wanted to be less restrictive. The DON further stated that all residents are monitored every two hours, so this would not be considered an intervention to prevent Resident 3's falls. The DON stated Resident 3 should have been rounded (monitored) more frequently and should have had a sitter assigned prior to his fourth fall. The DON stated possible outcomes of Resident 3's continued falls could have been a fracture or serious injury due to Resident 3 being on blood thinner medication.A review of the facility policy and procedure titled Falls Clinical Protocol, dated 2001, indicated .as part of the initial assessment.the physician will help identify.history of falls and risk factors.staff will evaluate and document fall that occur while individual is in

the facility.staff and physician will identify pertinent interventions to try to prevent subsequent falls.

Event ID:

Facility ID:

If continuation sheet