Health inspection·October 20, 2025

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few recommendations during the meeting.On October 20, 2025, at 4:04 p.m., the immediacy was removed in the presence of the DON upon verification of implementation of the removal plan.Non-compliance of F-627 remained at the scope and severity of D no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings:A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty or discomfort in swallowing) and dementia (memory loss and confusion).A review of resident 1's Physician History and Physical, dated June 16, 2025, indicated Resident 1 did not have decision-making capacity.A review of Resident 1's Progress Notes, indicated the following: a. June 20, 2025, .Prior to hospitalization resident lived at home with dtr (daughter) and goal is to return home once medically stable.; and b. July 11, 2025, Resident 1 attempted to leave the facility. Resident 1 was placed on close monitoring with 1:1 sitter (a person providing one-on-one supervision, to ensure resident's safety).A review of the SBAR (Situation, Background, Assessment, and Recommendation - a communication framework used to structure conversations about patient updates between team members) dated July 17, 2025, indicated a Certified Nursing Assistant (CNA) called the Licensed Vocational Nurse (LVN) to the room stating Resident 1 had difficulty swallowing. Resident 1 was observed by LVN coughing and the LVN had to perform the Heimlich maneuver (a first aid method for choking). A review of the Care Plan, dated July 18, 2025, indicated, Focus.Resident was having difficulty swallowing.Goal.The resident will have no choking episodes when eating.Interventions/Tasks.Diet to be followed as prescribed.Monitor for.choking.A review of the Care Plan, dated August 8, 2025, indicated, .Focus.Elopement: Resident is at risk for elopement/exit seeking/wandering related to.dementia or other cognitive impairment.Interventions/Tasks.1:1 Sitter provided 24 hours.Administer medications as ordered, monitor for side effects.A review of the Care Plan, dated August 8, 2025, indicated, .Focus.Falls: Resident is at risk for falls.Interventions/Tasks.Anticipate and meet needs.Keep within supervised view as much as possible.A review of the Care Plan, dated August 9, 2025, indicated, .Focus.PT (Physical Therapy) .Interventions/Tasks.Pt (patient) will be able to safely ambulate with Supervision using FWW (front wheel walker) .A review of the care plans dated July 18, August 8, and August 9, 2025, indicated Resident 1 has difficulty in swallowing, at risk for elopement, and at risk for falls.A review of Resident 1's Minimum Dats Set (MDS - an assessment tool), Section C: Cognitive Patterns, dated September 30, 2025, indicated a Brief Interview of Mental Status (BIMS - a cognitive assessment tool), score of 5 (severely impaired).A review of Resident 1's MDS, Section GG (Functional Abilities), dated September 30, 2025, indicated the following:a.) Requires supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) related to self-care (eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene); andb.) Requires supervision or touching assistance related to mobility (roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-bed/chair transfer, toilet transfer, tub/shower transfer, car transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet).A review of Resident 1's Progress Notes, dated September 25, 2025, indicated the Speech Therapist (a speech-language pathologist, a professional who assessed, diagnosed, and treats speech, language, voice, and swallowing disorders) recommended diet downgrade to pureed diet (soft, smooth, pudding-like foods that require no chewing) due to difficulty swallowing.A review of the Physician Discharge Order, dated September 25, 2025, indicated, .Fortified (with added essential nutrients such as vitamins, minerals, or proteins to enhance nutritional values), NAS (no added salt) diet, pureed texture, thin consistency.A review of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056485 If continuation sheet Page 2 of 7 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 10/20/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Physical Therapy Discharge Summary, dated September 29, 2025, indicated there was a discharge recommendation for home health (skilled medical care provided in a person's home/place, prescribed by a doctor to help them recover, manage an illness, or improve their function) services and 24-hour care.A review of the Occupational Therapy (assisting people in regaining or improving their ability to perform everyday tasks such as dressing and personal care) Discharge Summary, dated September 29, 2025, indicated, .Constant supervision recommended for safety.A review of the Physician Discharge Order, dated September 29, 2025, indicated, .DC (discharge) to board and care (a type of Residential Care Facility for the Elderly - RCFE) on Tuesday 9/30/25 per family request, dme (durable medical equipment - medical supplies and equipment) will be provided by hospice.On October 13, 2025, at 11:23 a.m., the Social Services Director (SSD) was interviewed. The SSD indicated that if the family were unable to care for the resident at home, she would begin assisting the resident and working with the family to find an appropriate placement. She mentioned using an outside company to aid in the placement process, such as a Board and Care facility or an Assisted Living (AL- setting, which provides housing, meals, and personal care support for individuals who need assistance with Activities of Daily Living [ADLs] but do not require the intensive medical care provided by a nursing home).The SSD explained that she utilized a placement agency (a third-party agency not contracted with the skilled nursing facility ([SNF] -a healthcare facility offering 24-hour medical care and rehabilitation services to patients needing assistance with daily activities and medical treatments post-hospitalization or surgery) to evaluate the resident's needs, communicate with the resident and their family, and refer the resident to other facilities for placement. Specifically, for Resident 1, the placement agency assisted in searching for a suitable Board and Care or AL facility. The SSD stated she forwarded Resident 1's information to the placement agency, expecting that a representative from the agency would contact Resident 1 and their family.However, the SSD noted that although a representative from the placement agency was supposed to come and assess Resident 1, this assessment did not take place. Furthermore, the SSD acknowledged that she did not communicate with the unlicensed room and board facility where Resident 1 was discharged . She admitted she did not verify if the facility could meet Resident 1's needs, instead relying on the assumption that such facilities would not accept residents they are incapable of caring for.A review of progress notes for Resident 1 did not indicate documentation that the SSD verified the resident was discharged to a board and care, as indicated in the physician discharge order and not a room and board, which is not licensed facility to provide the required assistance, supervision, and care for Resident 1.On October 13, 2025, at 2:02 p.m., the Placement Specialist (PS) from (Name of Placement Agency) was interviewed. The PS stated she had contacts with facilities like B & C, AL, memory care (specialized support and living options for individuals with Alzheimer's disease [a specific type of dementia] or other forms of dementia), room and boards, and shelters. The PS stated she received a call from the SSD requesting assistance for Resident 1's placement. She stated that normally, she would access the resident or get report from the SSD or the nurses. She stated she did not go to the skilled nursing facility to see Resident 1 and assess her needs. The PS acknowledged that the resident went to a room and board and not a board and care facility. On October 13, 2025, at 2:56 p.m., during an interview with the SSD, she stated she just clarified with the PS that the place where Resident 1 was transferred was unlicensed, and it was a room and board. The SSD stated she was not aware the place was not a B & C.According to the California Code of Regulations, Title 22, Division 6. Licensing of Community Care Facilities, Chapter 8, Residential Care Facilities for the Elderly (RCFE), Article 1 defines a room and board as .a living arrangement where care and supervision is neither provided nor available. According to the California Code of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056485 If continuation sheet Page 3 of 7 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 10/20/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Regulations, Title 22, Division 6. Licensing of Community Care Facilities, Chapter 8, Residential Care Facilities for the Elderly (RCFE), Article 1 defines a RCFE as a housing arrangement chosen voluntarily by the resident, the resident's guardian, conservator or other responsible person where varying levels of care and supervision are provided.According to the California Code of Regulations, Title 22, Division 6. Licensing of Community Care Facilities, Chapter 8, Residential Care Facilities for the Elderly (RCFE), Article 1 defines care and supervision as .those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. Care and Supervision shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene;(B) Assistance with taking medication; as specified in Section 87575; (C) Central storing and distribution of medications, as specified in Section 87575; (D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87575; (E) Maintenance of house rules for the protection of residents; (F) Supervision of resident schedules and activities; (G) Maintenance and supervision of resident monies or property; (H) Monitoring food intake or special diets. On October 13, 2025, at 3:01 p.m., in the presence of the SSD, a telephone interview was conducted with the owner of room and board (ORB). He stated he had five residents in the house. He stated he lived in the house, and he did not have a 24-hour caregiver. He stated the other residents have IHSS (In-Home Supportive Services - a program that provides in-home help for eligible aged, blind, or disabled individuals to enable them to remain safely in their homes) provided by their family, or the family themselves would come to assist the residents. He stated Resident 1 did not have IHHS and her family did not visit.The ORB stated he gave Resident 1 regular food and that he was not aware she was on a pureed diet. On October 13, 2025, at 3:12 p.m., during an interview with the SSD, she stated she should have called (Name of the room and board) and verify if it was a safe place for Resident 1. The SSD stated she did not ensure Resident 1 had a safe discharge. In addition, the SSD stated moving forward, she would check and verify the agency's (placement agency) referral before sending the residents for placement during discharge. On October 13, 2025, at 3:55 p.m., during an interview with the Director of Nursing (DON), she stated she did not have any knowledge about the placement agency that was utilized by the facility. On October 15, 2025, at 10:28 a.m., during a telephone interview with the ORB, he stated the following: a. Transport brought the resident to the room and board, with one to two pairs of pajamas;b. He was aware Resident 1 was alert and had dementia;c. He received telephone calls from the placement agency on September 23, 24, and 25, 2025, informing him he would be receiving a resident with dementia on hospice care (a specialized type of care for people with a life-limiting illness, focusing on comfort, pain relief, and symptom management rather than cure) and that Resident 1's family would come and talk to him;d. He did not have any information regarding the care needed by the resident (Resident 1) before the resident was transferred to his house (referring to the room and board) on September 30, 2025; and e. He stated he received a call from the SSD on October 1, 2025, to check on Resident 1. In addition, he stated it was the first time he received a call from the SSD. On October 15, 2025, at 1:20 p.m., a concurrent interview and record review was conducted with the DON. She stated Resident 1 was discharged from the facility on September 30, 2025, and had a 1:1 sitter until the day she was discharged . The DON stated the mobility assessment on September 30, 2025, indicated Resident 1 needed supervision with self-care and mobility. She stated, needs supervision, meant somebody needs to be present, with the resident when performing a task. She explained when Resident 1 used (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056485 If continuation sheet Page 4 of 7 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 10/20/2025 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 056485 If continuation sheet Page 5 of 7 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 10/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate clinical records for one of four residents reviewed (Resident 1) when:1. Resident 1's Notice of Proposed discharged (Notice of Proposed Discharge - a written document from a healthcare facility that informs a resident and/or their representative of the facility's intent to end the resident's stay) issued on September 30, 2025 (the day of discharge), had signatures of the resident and her family. Resident 1 was cognitively impaired. In addition, Resident 1's family was not present when the NOPD was issued;This failure resulted in Resident 1 and her family not being able to exercise their right to appeal the proposed discharge to the state long-term care agency.2. The LVN (Licensed Vocational Nurse) did not accurately document the time of family notification when Resident 1 had a fall on August 10, 2025.This failure had the potential to prevent the family from making informed decisions, providing critical information to the care team, or being present during a moment of crisis.Findings:On October 13, 15, and 20, 2025, unannounced visits were conducted at the facility to investigate complaint allegations.1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive and persistent loss of intellectual functioning, especially with impairment of memory, thinking and personality change).A review of resident 1's Physician History and Physical, dated June 16, 2025, indicated Resident 1 did not have decision-making capacity.A review of Resident 1's Brief Interview of Mental Status (BIMS - a cognitive assessment tool), dated August 15, 2025, indicated a score of 3 (severely impaired).A review of Resident 1's Notice of Proposed Discharge (NOPD - a written document from the healthcare facility, informing the patient that they be leaving the facility), dated September 30, 2025, indicated Resident 1 and the responsible party (RP) were informed on the same day Resident 1 was discharged . The NOPD was signed by Resident 1 and the RP.On October 16, 2025, at 2:44 p.m., a telephone interview was conducted with Resident 1's RP. She stated she requested a copy of Resident 1's medical records from the facility and noticed somebody signed her name on the NOPD communication form. The RP stated she did not go to the facility on September 30, 2025. The RP stated she would sign her name with her married last name and not with her [NAME] name. The RP also stated when she signs, she would spell out her middle name.On October 20, 2025, at 1:04 p.m., during a telephone interview with the Social Service Director (SSD) in the presence of the Director of Nursing (DON), the SSD stated Resident 1's RP did not come to the facility on September 30, 2025. The SSD stated the NOPD was given on September 30, 2025, on the same day Resident 1 was discharged . She stated the RP was given the NOPD on September 1, 2025, but there was no available place at that time for Resident 1 to transfer to. She stated a second NOPD was given to Resident 1 and the RP on September 30, 2025, since a place for transfer was established. The SSD stated Resident 1 signed the NOPD form but she was not sure if Resident 1 also signed for the RP. The SSD stated if the RP was informed via the telephone and it should be indicated in the NOPD form. The SSD stated the NOPD form was explained to Resident 1, who signed the form. The SSD was asked why Resident 1 was allowed to sign to the NOPD form when it was clearly stated Resident 1 had cognitive impairment. The SSD stated Resident 1 was alert.The SSD stated the RP did not get the chance to exercise their rights to appeal the discharge on [DATE].On October 20, 225, at 1:04 p.m., during an interview with the DON, she stated if a signature was obtained via the telephone, the document should include the date and name of the staff member obtaining the signature.A review of the facility policy titled, Transfer and/or Discharge Notice, revised March 2024 indicated, .Residents and/or representatives are notified in writing and in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056485 If continuation sheet Page 6 of 7 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 10/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 056485 If continuation sheet Page 7 of 7