Arlington Gardens Care Center

physician progress notes.

The DON stated this was the only evidence she could provide regarding the

Resident 19's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated

Serious Mental Illness.

Does the individual have a serious diagnoses mental disorder such as.Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? A review of Resident 19's psychiatric consultation notes, dated January 21, 2025, indicated .No evidence of hallucinations or delusional thoughts.

The notes did not indicate a diagnosis of schizophrenia. A review of Resident 19's psychiatric consultation notes, dated February 11, 2025, indicated .patient has no behavior problems at this time.No evidence of hallucinations or delusional thoughts.

The notes did not indicate a diagnosis of schizophrenia. A review of Resident 19's hospital Discharge Summary, dated December 10, 2025, indicated discharge diagnoses including Delirium [serious disturbance in mental abilities that results in a decreased awareness of one's environment and confused thinking] with baseline dementia - improving.

The record did not include a diagnosis of schizophrenia. A review of Resident 19's Physician History and Physical, dated December 12, 2025, completed by the facility's physician, indicated: .Patient seems to be in no acute distress, reports is doing well, and there are no recent events per nursing staff reports. and Assessment and Plan.Schizophrenia m/b hallucinations.Continue quetiapine. A review of Resident 19's Comprehensive Psychiatric Evaluation, dated December 16, 2025, indicated .Taking Seroquel for agitation associated with dementia.

The record further indicated dementia with agitation and depression under psychiatric history.

The Assessment section indicated a checkmark next to Dementia with agitation and did not indicate a checkmark next to schizophrenia.

The record indicated to discontinue both quetiapine orders. A review of the facility's policies and procedures (P&P), titled, Psychotropic / Anti-Psychotic Medication Use / PASRR, dated December 2016, indicated: .Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident.Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders.Schizophrenia.Psychosis [severe mental condition in which thought and emotions are so affected that contact is lost with reality] in the absence of dementia . A review of the facility's clinical protocol, titled, Schizophrenia and Related Disorders, dated 2001, indicated: .The physician/practitioner and staff will identify and document individuals who have a history of schizophrenia.The practitioner will not newly diagnose a resident with a serious mental illness without evidence-based criteria that are documented in the resident's medical record.The rationale for the diagnosis will be based on a comprehensive assessment of the resident's physical, behavioral, mental status, psychosocial status, and comorbid conditions.

Documentation will include.the findings from the comprehensive assessment.the presence and duration of symptoms, behaviors, and disturbances consistent with current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for schizophrenia.that the symptoms, behaviors, and disturbances are not attributable to substances, medications, or other conditions .the effect the disturbance is having on the resident's function, self-care, or interpersonal relationships, in comparison to before the onset of the disturbance .

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self-administration are turned over to the nurse in charge for return to the family or responsible party.

indicated, .the blood pressure is generally defined as Normal when the systolic pressure is in the

84 mm/Hg .Hypotension is defined as blood pressure less than 100/60/Hg (sic) .reporting .report other information in accordance with facility policy and professional standards of practice .

A review of the facility policy and procedure titled, Charting and Documentation, dated July 2017, indicated, .the following information is to be documented in the resident medical record .changes in the resident's condition .the assessment data and/or any unusual findings obtained during the procedure .notification of family, physician, or other staff .

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prevent accidents.

an observation, interview, and record review, the facility failed to follow its established smoking

locked container as required by the facility's policy.This failure had the potential to create environmental risk, hazards and accidents such as fire and/or burn injuries.Findings:On January 6, 2026, at 9:08 a.m., Resident 20 was observed in the smoking patio area unsupervised. Resident 20 stated he was an independent smoker and did not require supervision. Resident 20 stated he was allowed to keep his smoking materials since he was an independent smoker.On January 7, 2025, at 9:19 a.m., an observation of Resident 20's room was conducted. Resident 20 shared a room with a resident who was on oxygen.

The sign on the outside of Resident 20's room indicated oxygen in use no smoking.On January 6, 2026, at 2:01 p.m., a concurrent interview and record review was conducted with the Social Service Director (SSD).

The SSD stated the facility process for smokers was to perform a smoking assessment to determine if the resident was an independent smoker or dependent smoker. If the resident was an independent smoker the resident would be allowed to keep their smoking material with them in a locked box and could smoke unsupervised.

The SSD stated Resident 20 was an independent smoker.

The SSD stated Resident 20 kept his smoking materials with him.

The SSD stated Resident 20 did not have a locked box for his smoking materials and the locked boxes were scheduled to arrive at the facility tomorrow (January 7, 2026).

The SSD further stated Resident 20 should have had a locked box for his smoking materials prior to allowing him to smoke independently.Resident 20's medical records were reviewed.Resident 20 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis cervical (narrowing of the spinal canal in the neck).The history and physical completed on October 21, 2025, indicated Resident 20 had the capacity to make decisions.The smoking assessment dated [DATE], indicated .smoking cigarettes .no impairment .level of assistance .independent .On January 7, 2026, at 10:42 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON).

The DON stated the facility policy for smoking was for a smoking assessment to be conducted by the SSD with the resident, inform the residents of the smoking policy which included the times and designated smoking area.

The DON stated the smoking assessment indicated Resident 20 was an independent smoker.

The DON stated independent residents were allowed to keep their smoking materials with them in a locked box.

The DON stated the facility did not currently have lock boxes available.A review of the facility policy and procedures titled Smoking Policy-Residents, undated indicated .upon admission, residents shall be informed about any limitations on smoking designated smoking areas .The staff shall consult with attending physician and Interdisciplinary Team (IDT) to determine any restrictions on a resident smoking privileges as needed Smoking articles for residents with smoking privileges: .Residents who have smoking privileges shall not be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession or at the bedside unless assessed as independent by the IDT .Patient will be provided a lock box .Smoking articles will be kept secured at the nursing station provided to the residents as requested and/ or needed .

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Arlington Gardens Care Center 3688 Nye Avenue Riverside, CA 92505

DON.

The DON stated the current diet order on the meal ticket for Resident 92 did not reflect the

3:34 p.m. an interview was conducted with the Registered Dietitian (RD).

The RD stated Resident 92

further stated that the nursing staff or the kitchen supervisor should have communicated with her the discontinuation of the fluid restriction and updated the resident's diet order. A review of the facility policy and procedures titled, Physicians Orders, Accepting, Transcribing and Implementing (noting), dated January 2017, indicated, .Licensed nursing personnel will ensure that written (noting), telephone, and verbal orders will be recorded and implemented.

All physician orders are to be complete and clearly defined to ensure that accurate implementation.licensed nursing shall verify each order for completeness, clarity and appropriateness.record order changes in nursing notes.

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During an interview on [DATE], at 3:10 p.m., Registered Nurse 1 (RN 1) stated used fentanyl patches

the fentanyl patch contained medication after removal from the resident.

The DON stated the nurses

acknowledged the risk of diversion for used fentanyl patches when stored in the medication cart.

During a telephone interview on [DATE], at 8:33 a.m., the CP stated the CSR should account for used fentanyl patches with matching quantities.

The CP stated a nurse who took a used fentanyl patch would never be caught without proper documentation.

During an interview on [DATE], at 10:54 a.m., the DON stated nurses reviewed the medication cart's narcotic inventory at each shift change for accountability.

The DON stated this accountability review for used fentanyl patches was not documented. A review of the facility's P&P, titled, Controlled Substances, dated [DATE], indicated: .an individual resident controlled substance record is made for each resident.This record contains.quantity received.number on hand.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.The system of reconciling the receipt, dispensing and disposition of controlled substances includes.Records of personnel access and usage.Medication administration records.Declining inventory records.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.The nurse coming on duty and the nurse going off duty make the count together and document. 3.

During a concurrent observation and interview on [DATE], at 3:40 p.m. with LVN 5, Medication Cart 1 was reviewed.

The medication cart contained one box of fentanyl 25 mcg/hr patches for Resident 123.

The box contained one opened foil packet containing a used fentanyl patch.

The patch was stuck onto the inside of the foil packet. LVN 5 stated the nurses put used fentanyl patches into the opened foil packets like this and stored in the medication cart. LVN 5 stated the used patch was labeled 0800 [DATE] which meant the patch was placed at 8:00 a.m. on [DATE].

During a concurrent interview and record review on [DATE], at 3:57 p.m. with LVN 5, Resident 123's fentanyl administration record, dated [DATE], to [DATE], was reviewed.

The record indicated LVN 1 placed a fentanyl patch on Resident 123 at 8:08 a.m. on [DATE].

The record further indicated the fentanyl patch was removed by LVN 7 at 8:15 a.m. on [DATE]. LVN 5 stated the used fentanyl patches were given to the Director of Nursing (DON) for destruction when all five patches in the box were used.

During an interview on [DATE], at 3:10 p.m., RN 1 stated all narcotics were given to the DON for destruction. RN 1 stated used fentanyl patches were stuck to the foil packet before giving to the DON.

During a telephone interview on [DATE], at 8:33 a.m., the CP stated incorrect disposal of fentanyl patches could cause death.

The CP stated used fentanyl patches contained between 25% and 30% of the fentanyl dose after removal.

The CP stated there was a risk drug addicts could unfold a folded fentanyl patch or remove a fentanyl patch stuck to foil.

During an interview on [DATE], at 10:54 a.m., the DON stated nurses were supposed to fold used fentanyl patches in half after removing from the resident. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for fentanyl patches, dated [DATE], retrieved from DailyMed, indicated: .Proper handling of fentanyl transdermal system is necessary in order to prevent serious adverse outcomes, including death, associated with accidental secondary exposure to fentanyl transdermal system.Instruct patients to dispose of used patches immediately upon removal by folding the adhesive side of the patch to itself.Expired, unwanted, or unused fentanyl transdermal systems should be disposed of by folding the patch so that the adhesive side of the patch adheres to itself. A review of the facility's P&P, titled, Controlled Substances, dated [DATE], indicated: .Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances.

Fentanyl patches are disposed of in one of the following ways.By folding in half, sticky sides together and flushing down the toilet.Using approved drug disposal products specifically for fentanyl patches.

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During an interview on January 7, 2026, at 12:40 p.m., the Director of Nursing (DON) stated all residents on anticoagulants, including heparin, were monitored for bleeding and bruising.

During a concurrent interview and record review on January 7, 2026, at 1:18 p.m. with the DON, Resident 123's physician's orders were reviewed.

The physician's order, dated January 2, 2026, indicated to Monitor for S/S [signs and symptoms] of bleeding q [every] SHIFT e.g.

Epistaxis [nosebleed], Blood Stool, Bruising, Notify MD [physician] for any of the above changes. Resident 123's December 2025 and January 2026 Medication Administration Records (MAR, daily documentation record used by a licensed nurse to document medications and treatments given to a resident) were also reviewed. Resident 123's MARs indicated Resident 123 received at least one dose of heparin per day from December 28, 2025, to January 1, 2026.

The record did not indicate the facility monitored Resident 123 for signs and symptoms of bleeding on these dates.

The DON stated Resident 123 started heparin on December 27, 2025, and the monitoring for bleeding started on January 2, 2026.

The DON stated the facility's protocol was to have orders to monitor bleeding for all residents on anticoagulants. A review of Resident 123's care plans, dated December 28, 2025, indicated a care plan for anticoagulant medication.

The care plan indicated: .Assess for signs signifying blood loss (e.g., petechiae [tiny bleeding spots under the skin], bruises, dark-colored stools, etc.) . and .Monitor for bruising or bleeding . A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for heparin injection, dated April 15, 2025, retrieved from DailyMed, indicated: .Fatal hemorrhages [excessive bleeding] have occurred.Hemorrhage is the chief complication that may result from heparin therapy.

Bleeding can occur at any site. A review of the facility's clinical protocol, titled, Anticoagulation - Clinical Protocol, dated 2001, indicated: .The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems.

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During a medication pass observation on January 5, 2026, at 9:07 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed administering four medications to Resident 36.

The medications included one tablet of metformin (medication to treat diabetes) 1000 milligrams (mg).

LVN 1 asked Resident 36 if he had eaten breakfast yet. Resident 36 stated he did not eat breakfast and would eat a banana later. Resident 36 had a physician's order, dated November 5, 2025, for metformin 1000 mg, Give 1 tablet by mouth two times a day for DM type II [diabetes mellitus type 2, disorder characterized by difficulty in blood sugar control] give with food.

During an interview on January 5, 2026, at 12:45 p.m., LVN 1 stated Resident 36's metformin was not given with food. 2.

During a medication pass observation on January 5, 2026, at 9:20 a.m., LVN 1 was observed administering eight medications to Resident 111.

The medications included one tablet of potassium chloride (medication to treat low potassium levels) extended release (ER) 10 milliequivalents (mEq, a unit of measurement). Resident 111 had physician's orders, dated November 14, 2025, for potassium chloride ER 10 mEq Give 1 tablet by mouth two times a day for hypokalemia [low potassium levels] Give with meals.

During an interview on January 5, 2026, at 12:45 p.m., LVN 1 stated Resident 111's potassium chloride orders indicated to give with a meal. LVN 1 stated the potassium tablet was given to Resident 111 after a meal. 3.

During a medication pass observation on January 5, 2026 at 9:47 a.m., LVN 1 was observed administering 11 medications to Resident 69.

The medications included one tablet of potassium chloride ER 10mEq. Resident 69 had physician's orders, dated November 3, 2025, for potassium chloride ER 10 mEq Give 10 mEq by mouth one time a day for Hypokalemia Give with food.

During an interview on January 5, 2026, at 12:40 p.m., LVN 1 stated Resident 69's potassium chloride was administered after Resident 69 ate breakfast. LVN 1 stated the physician's orders to give the medication with food were not followed.

During a telephone interview on January 8, 2026, at 8:33 a.m., the Consultant Pharmacist (CP) stated giving medications after eating was not following the physician's orders to give with food.

The CP stated potassium chloride was given with food to prevent stomach upset.

The CP stated nurses should offer residents food with the medication to follow the physician's orders to take with food.

During an interview on January 8, 2026, at 10:47 a.m., the Director of Nursing (DON) stated if the physician's orders indicated to give a medication with food, the nurse needed to give the medication with food. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for metformin tablets, dated September 6, 2012, retrieved from DailyMed, indicated: .Metformin.should be given in divided doses with meals. and .Common side effects of Metformin.include diarrhea, nausea, and upset stomach.Taking your medicine with meals can help reduce these side effects. A review of the PI for potassium chloride ER tablets, dated November 18, 2025, retrieved from DailyMed, indicated: .Take potassium chloride extended-release tablets with meals and with a glass of water or other liquid. Do not take on an empty stomach because of its potential for gastric irritation. A review of the facility's policies and procedures (P&P), titled, Administering Medications, dated April 2019, indicated: .Medications are administered in accordance with prescriber's orders.

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Arlington Gardens Care Center 3688 Nye Avenue Riverside, CA 92505

During a concurrent observation and interview on [DATE], at 3:05 p.m. with Licensed Vocational Nurse 2 (LVN 2), Medication room [ROOM NUMBER] was toured.

The medication fridge contained one box of epinephrine (a medication to treat medical emergencies) 0.3 milligram (mg) auto-injector (medical device to inject a premeasured medication dose) labeled for Resident 92. LVN 2 stated the epinephrine auto-injector pens were not supposed to be stored in the refrigerator. 2.

During a concurrent observation and interview on [DATE], at 3:05 p.m. with LVN 2, Medication room [ROOM NUMBER] was toured. LVN 2 stated Resident 92's epinephrine auto-injector expired on [DATE], and the medication was not good.

During an interview on [DATE], at 3:52 p.m., the Director of Nursing (DON) stated expired medication needed to be discarded.

The DON acknowledged Resident 92's epinephrine auto-injector was expired and inappropriately stored in the refrigerator. Resident 92 had a physician's order, dated [DATE], for EPINEPHrine Injection Solution Auto-injector 0.3 MG/0.3ML [milliliters] Inject 0.3 ml intramuscularly [into the muscle] as needed for Anaphylaxis [sudden and severe allergic reaction]. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for epinephrine auto-injector, dated February 15, 2023, retrieved from DailyMed, indicated: .Store at 20 C to 25 C (68 F to 77 F). and .Do not refrigerate. and .Properly dispose all used, unwanted or expired epinephrine.auto-injectors. A review of the facility's P&P, titled, Storage of Medications, dated [DATE], indicated: .Drugs.are stored.under proper temperature.controls. and .Discontinued, outdated, or deteriorated drugs.are returned to the dispensing pharmacy or destroyed. 3.

During a concurrent observation and interview on [DATE], at 3:50 p.m. with LVN 5, Medication Cart 1 was reviewed.

The medication cart contained an opened pouch with a Symbicort (medication used for chronic obstructive pulmonary disease [COPD], a lung disease causing breathing problems) 80-4.5 micrograms (mcg, a unit of measurement) inhaler for Resident 127. LVN 5 stated nurses were supposed to label all inhalers with an open date immediately after opening. LVN 5 stated Resident 127's Symbicort inhaler wasn't labeled and it should have been.

During an interview on [DATE], at 3:52 p.m., the DON stated Resident 127's Symbicort inhaler was supposed to be labeled with the date it was opened. Resident 127 had a physician's order, dated [DATE], for Symbicort 80-4.5 mcg, 2 puff inhale orally [by mouth] two times a day for COPD. A review of the PI for Symbicort, dated [DATE], retrieved from DailyMed, indicated: .The inhaler should be discarded when the labeled number of inhalations have been used or within 3 months after removal from the foil pouch. A review of the facility's P&P, titled, Administering Medications, dated [DATE], indicated: .When opening a multi-dose container, the date opened is recorded on the container.

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serve food in accordance with professional standards.

food in accordance with professional standards for food safety when one unopened carton of 237 ml

September 24, 2025, was found stored in residents' refrigerator # (number) 1 located in nurse's station 1.This failure had the potential to cause foodborne illnesses when consumed by a medically vulnerable resident.Findings:On January 7, 2026, at 10:38 a.m., an inspection of Residents' refrigerator #1 located in Nurse's Station 1 was conducted with Licensed Vocational Nurse (LVN) 9.

One unopened carton of 237ml Boost with an expiration date of September 24, 2025, was found stored in Residents' refrigerator #1 and readily available for consumption. LVN 9 stated the expired Boost should have been discarded since it had an expiration date of September 24, 2025. LVN 9 stated she was not sure why the expired Boost was still in the refrigerator when the residents' refrigerator was inspected daily by the staff.

During an interview on January 7, 2026, at 2:25 p.m., with the Director of Nursing (DON), she stated the facility did not have Boost for nutritional supplements.

She stated the facility staff should check for expiration dates when receiving food brought from home and should be labeled and dated.

She also stated there should be no expired food in the residents' refrigerator.During an interview on January 7, 2026, at 11:20 a.m., with the Dietary Supervisor (DS), she stated there should be no expired food in the refrigerator including the residents' refrigerator.

During an interview on January 9, 2026, at 12:28 p.m., with the Registered Dietician (RD), she stated food brought from home should be dated and labeled.

She stated the nurses should check for the expiration date.

She stated there should be no expired food in the refrigerator.

The RD stated expired food when consumed could cause the resident to get sick.The facility policy and procedure titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES, revised July 18. 2023, indicated, .Food items are inspected for safety.before they are stored and/or served in accordance with food safety standards.Perishable food that requires refrigeration, can be stored for the resident in the refrigerator.If unopened, refrigerated/frozen items will be disposed of by the expiration date on the container.The facility policy and procedure titled, Foods Brought by Family/Visitors, dated May 28, 2025, indicated, .The nursing staff will discard perishable foods on or before the use by date.

During an interview on January 6, 2026, at 11:54 a.m., the IP verified it was not appropriate to use alcohol wipes to sanitize shared equipment, such as the BP cuffs and glucometers, between residents.

During a concurrent interview and record review on January 8, 2026, at 9:54 a.m. with the IP, the facility's P&P, titled, Cleaning and Disinfection of Environmental Surfaces, dated June 2009, was reviewed.

The IP stated the following policy excerpt indicated BP cuffs needed to be wiped with bleach between uses: .Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products.

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