Arlington Gardens Care Center
ARLINGTON GARDENS CARE CENTER in RIVERSIDE, CA — inspection on October 20, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
the restroom, somebody should be with her going to the restroom because she could fall.
The DON stated the expectation was for the receiving facility to have the knowledge, training, and skills needed to care for the resident.On October 15, 2025, at 1:40 p.m., during a telephone interview with the ADM, he stated the placement agencies were used as a resource to assist with resident placement, and his expectation was for the facility staff to verify that receiving facility can meet the resident's needs to ensure a safe and appropriate discharge.Seven days after the resident was discharged from the skilled nursing facility to the room and board, Resident 1's family had her transferred via ambulance to the general acute care hospital (GACH) on October 7, 2025.A review of Resident 1's GACH record titled, Emergency Record, dated October 7, 2025, indicated, .from SNF (sic).Family AMA'd (against medical advice-leaving the facility against the advice of a medical professional) pt (patient) due to disappointment regarding care at the facility.A review of Resident 1's Urinalysis (a laboratory test that examines a sample of urine), and Bacteriology (a laboratory test that detects bacteria), dated October 7, 2025, indicated Resident 1 had a urine infection.A facility policy and procedure specific on managing safe discharge was requested but the facility did not have this policy and procedure.A review of the facility's policy and procedure titled, Transfer or Discharge Notice, revised March 2021, indicated, .In determining the transfer location for a resident, the decision to transfer to a particular location is determined by the needs, choices and best interests of the residents.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arlington Gardens Care Center
3688 Nye Avenue Riverside, CA 92505
SUMMARY STATEMENT OF DEFICIENCIES
language and format that understand at least thirty (30) days prior to transfer or discharge.Residents are permitted to stay in the facility and not be transferred or discharged unless.the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility.Residents have the right to appeal.a transfer or discharge through the state agency that handles appeals.2. A review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation - a communication framework used to structure conversations about patient updates between team members) Communication Form, dated August 10, 2025, indicated Resident 1 had a witnessed fall and Resident 1's daughter was notified on August 10. 2025, at 12 a.m.On October 20, 2025, at 1:33 p.m., during a concurrent interview and record review with the DON, she stated Resident 1 had a witnessed fall on August 10, 2025, with no injury.
She stated a fall incident was considered a change in condition.
She stated the resident's physician, and RP should be notified.
The DON stated the documented time of 12 a.m., was probably incorrect.
She stated the nurses were expected to document accurately.
She also stated there was no other documentation regarding family notification.On October 20, 2025, at 3:51 p.m., during a telephone interview with the Licensed Vocational Nurse (LVN), she stated Resident 1 had witnessed fall.
The LVN could not remember the exact date and time the fall incident happened.
She stated it was around the evening time.
The LVN stated she called the RP and left a message.
She stated she called the RP the second time and there was no answer.
She stated she did not leave any message on her second call.
She stated she initiated the first call immediately after she received an order from Resident 1's physician.
The LVN stated she should have changed the time to reflect the actual time she called the RP.
The LVN stated she could not recall if she documented any of her calls to Resident 1's RP in the progress notes.A review of the facility policy titled, Charting and Documentation, revised July 2017, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.Documentation in the medical record will be.complete, and accurate.
Facility ID: