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 Page 1 of 2 056485 056485 12/17/2025 Arlington Gardens Care Center 3688 Nye Avenue Riverside, CA 92505

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administer, and then document in the eMAR the medications administered to the resident;- Whoever administered the medication to the resident should sign the eMAR.On December 31, 2025, at 1:24 p.m., during a telephone interview, LVN 1 stated LVN 2 should have signed for the medications she administered to Resident 1. A review of the facility's undated policy and procedure titled, Medication Administration-General, indicated, .medications are administered as prescribed, in accordance with good nursing principles and practices .except for single unit dose packet distributions systems, only the licensed or legally authorized personnel who prepare a medication may administer it.This individual records the administration on the residents MAR at the time the medication was given.A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed . 056485 Page 2 of 2