Health inspection·June 18, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the proposed transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was provided to the resident and/or resident's representative in accordance with the policy and procedure for two of 23 sampled residents (Residents 3 and 8). This failure resulted in missed opportunity for the LTC Ombudsman to advocate for the residents to ensure a safe and appropriate discharge. Findings: On May 22, 2025, at 10:15 a.m., an unannounced visit was conducted to the facility to investigate one complaint related to transfer and discharge Process. A review of Resident 3's record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included fracture of the pelvis (hip bones fracture). A review of Resident 3's physician's order dated May 14, 2025, indicated, DC (discharge) to board and care on hospice Wednesday 5/14/2025 . A review of the Social Service notes dated May 13, 2025, indicated, .DC to board and care on hospice Wednesday 5/14/2025 . A review of Resident 3's proposed discharge/transfer notice indicated the resident signed the notice on May 13, 2025. A review of the fax document sent to the Ombudsman on May 14, 2025, indicated Resident 3's proposed discharge/transfer notice was sent to the Ombudsman on May 14, 2025, (1 day after the notice was given to the family member). A review of Resident 8's record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included coronary artery disease and had coronary artery bypass grafting (CABG - a heart procedure that reroutes blood around blocked arteries to improve the blood flow). A review of the physician's order dated May 16, 2025, indicated .Pt (patient) will dc home Friday 5/16/25 . (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 06/18/2025 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)