Health inspection·June 6, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. 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 a safe and orderly discharge was provided for one of three sampled residents (Resident 1), when the discharge location was not confirmed with family before transferring the resident. Residents Affected - Few This failure had the potential for Resident 1 to be discharged to the wrong address which could cause anxiety to the family and to the resident. Findings: On June 6, 2024, an unannounced visit was conducted at the facility to investigate a complaint on admission, transfer, and discharge rights issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses which included acute respiratory failure (when lungs cannot release enough oxygen into the blood), Type 2 diabetes (long-term condition in which body has trouble controlling blood sugar), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and hypertension (force of the blood against the artery walls is too high). A review of Resident 1's history and physical dated February 28, 2024, indicated resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized comprehensive assessment and care planning tool) section GG (which indicates functional abilities and goals) dated March 11, 2024, indicated Resident 1 needed maximum assistance with ADLs (Activities of daily living). A review of Resident 1's physician orders dated May 28, 2024, indicated .discharge 5/29/2024 home with (family member) . A review of Resident 1's Progress Notes dated May 29, 2024, by the Social Service Director (SSD) indicated, received a call from transportation regarding insufficient address for pt (patient). The SSD called a family member to confirm the correct address. Per family member, he requested for the pt be sent back to skilled nursing facility until the following day and he will pick her up. The family member expressed some concerns and will address them I the morning. Pt will return to ag (skilled nursing facility) for the night and dc (discharge) home safely tomorrow. On May 6, 2024, during an interview, Registered Nurse (RN) stated, during a discharge the SSD and the Case Manager (CM) would confirm if the resident's address was right. (continued on next page) 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 Page 1 of 2 Event ID: 056485 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 056485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 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)