Shields Nursing Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

LVN 1 stated her mistake was that she did not notify physician of failed attempts to obtain UA specimen.

LVN 1 stated Resident 1 complained of pain after receiving routine Tylenol. LVN 1 stated she did not informed physician that Resident 1 continued to complain of pain. LVN 1 said she did not document order for straight catheter in Resident 1's records. LVN 1 stated when she returned the next day, Resident 1 had low grade fever and low oxygen saturation. LVN 1 stated she called the doctor and received an order to transfer Resident 1 to the hospital. During a concurrent interview and record review on 9/29/25 at 4:20 p.m. with DON, LVN 1 and Administrator (Admin), Resident 1's Progress Notes, dated 1/10/25 through 1/17/25, and laboratory reports were reviewed. Resident 1's Progress Notes, dated 1/16/25, indicated LVN 1 received an order from the physician the previous day. DON stated she was not aware that Resident 1's STAT lab order for UA was endorsed from shift to shift. DON stated she did not know that Resident 1's STAT lab orders was received a day before Resident 1 was transferred to the hospital. DON stated the progress notes did not reflect the time upon which the physician order for STAT labs was received.During a review of

the facility's P&P titled, Lab and Diagnostic Test Results-Clinical Protocol, dated November 2018, the P&P indicated, The staff will process test requisitions and arrange for tests. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. During a review of the facility's P&P titled, Pain-Clinical Protocol, dated October 2022, the P&P indicated, If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper analgesic medications to the extent possible. During a review of the facility's P&P titled, Intake, Measuring and Recording, dated October 2010, the P&P indicated, The purpose is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Review the resident's care plan to assess for any special needs of the resident. At the end of your shift, total the amounts of all liquids the resident consumed.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Nursing Center

3230 Carlson Boulevard El Cerrito, CA 94530

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents' medical records was accurately documented and systematically organized when Licensed Vocational Nurse (LVN1) did not document in Resident 1's medical records, the physician order to obtain STAT laboratory test for urinalysis (UA) and straight catheterization to include the date and time the order was received in accordance with accepted professional standards and practices.This failure had the potential to cause inaccurate documentation and confusion of care and treatment provided for Resident 1.

During an interview on 9/29/25 at 3:25 p.m. with LVN 1, LVN 1 stated an order for a STAT lab test for UA, blood work and straight catheter to obtain UA specimen were received for Resident 1 a day before Resident 1 was transferred to the hospital. LVN 1 stated she attempted to obtain urine specimen by straight catheterizing Resident 1 twice but there was no urine. LVN 1 stated she endorsed the STAT order for UA to

the night shift nurse. LVN 1 stated her mistake was that she did not notify the physician of failed attempts to obtain UA specimen. LVN 1 stated Resident 1 complained of pain after receiving routine Tylenol. LVN 1 stated she did not inform the physician that attempts to obtain urine specimen failed. LVN 1 stated she did not informed physician that Resident 1 continued to complain of pain. LVN 1 said she did not document order for straight catheter. LVN 1 stated when she returned the next day, Resident 1 had low grade fever and low oxygen saturation. LVN 1 stated she called the doctor and received an order to transfer Resident 1 to hospital. During a concurrent interview and record review on 9/29/25 at 4:20 p.m. with DON, LVN 1 and Administrator (Admin), Resident 1's Progress Notes, dated 1/10/25 through 1/17/25 and laboratory reports dated 1/16/25, were reviewed. Lab report for STAT UA specimen was received 1/16/25 at 10:15 a.m.

Resident 1 Progress Notes, dated 1/16/25 at 00:20 indicated that LVN1 received orders from the physician

the previous day. DON stated she was not aware that Resident 1's STAT lab order for UA was endorsed from shift to shift. DON stated she did not know that Resident 1's STAT lab orders was received a day

before Resident 1 was transferred to the hospital. DON stated the progress notes did not reflect the time upon which physician order for STAT labs was received.

Event ID:

Facility ID:

If continuation sheet