Health inspection·December 17, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review on one of three residents (Resident 1) reviewed for medication administration, the facility failed to ensure medication administration was conducted in accordance with professional standards of practice when LVN 2 prepared and administered some of Resident 1's medications but did not sign the medication administration record. This failure resulted in inaccurate medication administration record and had the potential for Resident 1 and/or other residents for medication error. Findings:On December 17, 2025, at 9:08 a.m., an unannounced visit was conducted at the facility to investigate a quality care issue. On December 17, 2025, at 11:12 a.m., during an interview, LVN 1 stated:She (LVN 1) was the licensed nurse assigned to Resident 1 on December 2, 2025;- LVN 2 assisted her with the 9 a.m. med pass for Resident 1 on December 2, 2025;- LVN 2 prepared the prescription medication (RX- medications that cannot be purchased and dispensed without a prescription from a physician, usually delivered in a bubble pack) in a medicine cup and administered the medication to Resident 1 at 9 a.m.; She (LVN 1) recalled administering three to four OTC medications and an insulin to Resident 1 on December 2, 2025, at 10 a.m.On December 17, 2025, at 2:14 p.m., an interview was conducted with LVN 2. LVN 2 stated:- She assisted LVN 1 with her med pass on December 2, 2025; and - She and LVN 1 went over the residents' electronic Medication Administration Record (eMAR), and she poured the residents' medication in a cup, handed them to LVN 1 to administer to the residents. On December 17, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses of diabetes mellitus (high blood sugar).Resident 1's Minimum Data Set (MDS- an assessment tool), dated November 25, 2025, indicated Resident 1 had has moderate cognitive impairment.A review of the eMAR, dated December 2025, indicated LVN 1 administered the following medications to Resident 1 on December 2, 2025, at 9 a.m.:- Ascorbic acid (OTC supplement) 500 milligrams (mg - unit of measurement) tabletBenicar oral tablet 5 mg tablet (RX-medication used to treat high blood pressure;- Glipizide oral tablet 2.5 mg (RX-medication used to treat high blood sugar);- Lactinex oral packet (OTC dietary supplement);Lantus insulin 20 units (RX - medication to treat diabetes);- Multivitamins with minerals tablet (OTC supplement);- Oxybutynin chloride 5 mg tablet (RX medication used to treat bladder spasm;- Prednisone 5 mg tablet (RX medication used to treat inflammatory conditions);- Rosuvastatin Calcium 20 mg tablet (RX medication used to lower cholesterol);- Sirolimus 0.5 mg tablet (RX medication used to prevent organ rejection after a kidney transplant);- Trulicity injection 0.5 milliliter (RX medication used to treat high blood sugar);- Prograf oral packet (RX medication used to prevent body from rejecting a transplanted organ such as kidney); and- sodium bicarbonate 650 mg tablet (OTC supplement medication).Further review of the eMAr did not indicate documentation reflecting the medications prepared and administered by LVN 2 to Resident 1 on December 2, 2025. On December 17, 2025, at 2:55 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated:-The standard practice for medication administration is for the licensed nurse to prepare, Residents Affected - Few (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 12/17/2025 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)