Shields Richmond Nursing Center

F-F800).

A review of facility's document titled, Nutrition Therapy Essentials - Registered Dietician Consultant Services Agreement, dated, 2/1/23, the agreement indicated, .V. COMPENSATION .2. Contracted hours for the Facility will be 16 hours a week as negotiated with Consultant and Facility's appointed person of contact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0801 A review of the California Code, Health and Safety Code - HSC S 1265.4 (HSC), the HSC indicated, (a) A licensed health facility .shall employ a full-time, part-time, or consulting dietitian. A health facility that employs Level of Harm - Minimal harm or a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets potential for actual harm the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. Residents Affected - Some (b) The dietetic services supervisor shall have completed at least one of the following educational requirements:

(1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility.

(2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration.

(3) A graduate of a dietetic assistant training program approved by the American Dietetic Association.

(4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is

a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.

(5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.

(6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision.

(7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 40968

Residents Affected - Some Based on observation, interview, and document review, the facility failed to store, prepare, and serve food under sanitary conditions when:

1. [NAME] 1 prepared food in the emergency three compartment sink.

2. Open package pasta was not stored in airtight container.

3. 12 Quart clear container stored multiple sprouted, soft, and wrinkled red potatoes.

4. Powdered sugar in tin can labeled with used by 4/10/25.

5. One and half pint cherry tomatoes was not labeled and dated with used by.

6. 12 Quart full container with wrinkled, mushed, liquified cherry tomatoes were stored.

7. Unlabeled 12 ounce (oz - unit of measurement) clear plastic container contained; a. four green bell peppers that were extremely soft with white fuzzy matter and discoloration; b. three wrinkled red bell peppers had caked in black matter and white fuzzy discoloration, two yellow peppers were wrinkled.

8. Two 16 oz containers had mushy strawberries with liquid juice was labeled with delivery date 4/7/25.

9. One dented can good was stored with ready to use cans.

10. Mounted can opener had a reddish and brown flaky coating on surface near the blade.

These failures had the potential to cause food borne illness to residents who receive food from the kitchen out of a facility census of 64.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0812 During the initial tour of the kitchen on 4/14/25, at 9:38 a.m., in the presence of Dietary Service Supervisor (DSS) and Registered Dietician (RD), the following was observed; 1. [NAME] (CK) 1 prepared food in the Level of Harm - Minimal harm or emergency three compartment sink. 2. Open package of pasta was not stored in airtight container. 3. 12 potential for actual harm Quart clear container stored multiple sprouted, soft, and wrinkled red potatoes. 4. Powdered sugar in tin can labeled with used by 4/10/25. 5. One and half pint cherry tomatoes was not labeled and dated with used by. Residents Affected - Some 6. 12 Quart full container with wrinkled, mushed, liquified cherry tomatoes were stored. 7. Unlabeled 12 ounce (oz - unit of measurement) clear plastic container contained; a. four green bell peppers that were extremely soft with white fuzzy matter and discoloration; b. three wrinkled red bell peppers had caked in black matter and white fuzzy discoloration; c. two yellow peppers were wrinkled and soft. 8. Two 16 oz containers had mushy strawberries with liquid juice was labeled with delivery date 4/7/25. 9. One dented can good was stored with ready to use cans. 10. Mounted can opener had a reddish and brown flaky coating on surface near the blade.

During a concurrent observation and interview on 4/14/25, at 9:43 a.m., with RD, the RD acknowledged CK 1 prepared food in the three-compartment sink. RD stated, the sink should not have been used as food preparation area due to risk of cross contamination with food and pathogen from sink.

During an interview on 4/14/25, at 9:45 a.m., with DSS, DSS stated staff were used to using the three-compartment sink as food preparation area and it was hard to undo. DSS further stated, staff needed re-training to not use the sink for food preparation.

During a review of facility's policy and procedure (P&P) titled, FOOD PREPARATION, dated 2023, the P&P indicated, Employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness.

During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, the P&P indicated, Food preparation should not occur in two or three compartment sinks.

During a concurrent observation and interview on 4/14/25, at 9:50 a.m., with DSS, DSS attempted to seal the open package of pasta with plastic wrap. DSS stated, staff forgot to put the open package of pasta in airtight container. DSS added, there was potential for pest to get inside unsealed package.

During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, the P&P indicated, under PROCEDURES: .9. Metal, plastic containers (with tight fitting lids and NSF approved), or resealable plastic bags will be used for staples and opened packages of items such as pastas, rice, dry cereals, etc.

During a concurrent observation and interview on 4/14/25, at 9:54 a.m., with DSS, DSS discarded the unlabeled container of cherry tomatoes and stated the tomatoes may possibly be stored beyond used by. DSS added, kitchen staff would not know when the tomatoes could be used and discarded because it was not labeled.

During a concurrent observation and interview on 4/14/25, at 10:11 a.m., with RD, RD stated the sprouted tomatoes and wrinkled, soft cherry tomatoes were compromised and should have been discarded. RD also stated, there was potential for the residents in the facility to get sick if compromised food items were ingested.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0812 During a review of facility's PRODUCE STORAGE GUIDELINES, dated 8/15, on 4/14/25, at 10:19 a.m., with DSS, the guidelines indicated, strawberries are to be stored in the refrigerator for 3-5 days. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/14/25, at 10:25 a.m., in the presence of DSS, one dented can of six-pound sweet potatoes was stored in the rack along with ready to use can goods. Residents Affected - Some

During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, the P&P indicated, under PROCEDURES: .10. Canned food items should be routinely inspected for damage such as dented, bulging or leaking cans. These items should be set aside in a designated area for return to the vendor or disposed of properly.

During a concurrent observation and interview on 4/14/25, at 10:45 a.m., with RD, RD removed the can opener shaft from the mount and inspected the can opener. RD stated the can opener should not be used because of the rust. RD further stated rust could transfer toxin to food ingested by residents and residents could get sick.

During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, indicated under policy, Equipment will be cleaned and sanitized to prevent food borne illness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32717 potential for actual harm Based on observation, interview and record review, the facility failed to ensure infection prevention and Residents Affected - Few control procedures were followed when:

-Housekeeping Aide (HA) did not disinfect Resident 169's room, a contact precaution (a set of infection control practices used to prevent the spread of germs through direct or indirect contact. These precautions are implemented when a patient has a disease that can be transmitted by touching the patient, contaminated surfaces, or objects in their environment) room, with appropriate disinfectant.

-Registered Nurse (RN) 1 did not disinfect medical device with appropriate disinfectant in between resident use.

This failure had the potential to result in spreading Clostridium difficile (C. diff, a bacteria that causes diarrhea and colitis (inflammation of the colon). It's a serious infection that can be life-threatening, especially

in vulnerable populations like older adults in healthcare settings) infection to other residents.

Findings:

During a review of Resident 169's Admission Record, the Admission Record indicated Resident 169 was admitted to the facility on [DATE REDACTED] with diagnoses that included enterocolitis (an inflammation of both the small and large intestines. It can be caused by various factors, including bacterial infections) due to C. diff infection.

During an observation on 4/15/25, at 12:34 p.m., Resident 169's room had Contact Plus Precaution sign tucked inside a fabric door organizer.

During an interview on 4/16/25, at 10:01 a.m., with Housekeeping Aide (HA), HA stated, when entering Resident 169's room, she made sure to wear Personal Protective Equipment (PPE, a variety of equipment designed to protect the wearer from injury or illness, including clothing, helmets, gloves, face shields). HA stated she used the pink Ecolab Smartpower Sink and Surface sanitizer to clean the tables, doorknobs, cabinets, night stand, bed and bed frame, and left the sanitizer on for five minutes. HA stated she used the purple Oasis 499 Disinfectant Cleaner to clean the bathroom and the floor. HA stated these two chemicals came in pre-mixed.

During an interview on 4/16/25, at 10:12 a.m., with Infection Preventionist (IP), IP stated, for contact precaution rooms, housekeeping staff are supposed to use the orange top disinfectant wipes (Sani-Cloth Germicidal Disposable Wipe/Bleach), not the purple cleaner spray as it is only a cleaner and not a disinfectant.

During a follow-up interview on 4/16/25, at 10:30 a.m., with HA, HA stated she only used the spray solution, either the pink or purple, and wiped with cleaning towel. HA stated she did not use the Sani-Cloth disinfecting wipes and did not have any of those in the cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0880 During an interview on 4/16/25, at 11:43 a.m., with Registered Nurse (RN) 2, RN 2 stated they used the wrist BP cuff on all the residents and disinfected it with Clorox wipes and the Sani-Cloth disinfecting wipes, but Level of Harm - Minimal harm or most of the time used Clorox with the white top because Clorox was pretty good with everything. potential for actual harm

During an observation on 4/16/25, at 11:46 a.m., HA cleaned room [ROOM NUMBER] by spraying a wash Residents Affected - Few towel with the pink solution and wiped down the door, a walker that was at the bedside, cabinet, walls, overhead light, bed rails and overbed tables.

During a concurrent observation and interview on 4/17/25, at 11:20 a.m., with IP, IP stated any disinfecting wipes that has bleach could be used to disinfect a contact precaution room. An observation of a tub of Sani-Cloth disinfecting wipes with orange top indicated it is effective against Clostridium difficile spores.

During a concurrent observation and interview on 4/17/25, at 2:34 p.m., with Director of Nursing (DON), DON stated not being sure if the Clorox wipes with the white top contained bleach. Clorox wipes was found in the housekeeping cart that indicated Bleach-free.

During a review of the facility's policy and procedure (P&P) titled, Clostridium Difficile, last revised October 2018, the P&P indicated, the primary reservoir for C.difficile are surfaces, spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. Environmental cleaning in rooms of residents with C. difficile is done with a disinfecting agent recommended for C.difficile (e.g. household bleach and water solution or an EPA registered germicidal agent effective against C.difficile spores). Steps toward prevention and early intervention include disinfection of items with potential fecal soiling (e.g. commode chairs, bed rails, etc.) with a disinfecting agent recommended for C. diff.

During a review of the manufacturer's information of the Sani-Cloth Bleach Germicidal Disposable Wipe with EPA registration number 9480-8, the manufacturer's information indicated the wipes are effective against 52 microorganisms and is ideal for disinfecting high-risk areas contaminated with Clostridioides difficile spores.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 32717 potential for actual harm Based on interview and record review, for one randomly selected resident (Resident 369), the facility failed to Residents Affected - Few establish and implement infection prevention and control program that included antibiotic stewardship program when:

-Resident 369 was administered antibiotics without adequate indication.

-Resident 369's possible symptoms of antibiotic side effects were not monitored.

This failure had the potential to result in the development of antibiotic-resistant infections (occur when bacteria develop the ability to withstand the effects of antibiotics, making them difficult or impossible to treat, can be serious and even life-threatening, often requiring longer hospital stays, more expensive treatments, and potentially toxic medications).

Findings:

During a review of Resident 369's Admission Record, the Admission Record indicated Resident 369 was admitted to the facility in March 2024 with diagnoses that included hypertension (high blood pressure) and personal history of urinary tract infection.

During a review of Resident 369's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/31/25, the MDS indicated a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.

During a review of Resident 369's clinical record, Medication Review Report (MRR), dated 4/17/25, indicated

an order dated 3/25/25 for Cephalexin (treats infection) oral capsule 250 mg 1 capsule by mouth once daily for personal history of urinary tract infections. The clinical record did not indicate a urinalysis or urine culture was done.

During an interview on 4/16/25, at 12:10 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 369 had diarrhea in the morning and had to be taken to the bathroom because Resident 369 kept going. CNA 4 stated Resident 369 also had diarrhea/loose stools too on 4/15/25. CNA 4 also stated Resident 369 was feeling bad for the night shift CNAs for cleaning up after a big loose bowel movement.

During a joint interview on 4/16/25, at 12:19 p.m., with RN 2 and CNA 4, RN 2 stated he did not know about Resident 369 having episodes of diarrhea. CNA 4 reminded RN 2 that he had been told Resident 369 had been having diarrhea for two days. RN 2 stated, having loose stools was less serious than watery stools and

it was normal for residents to use the bathroom constantly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0881 During an interview on 4/16/25, at 12:20 p.m., with Resident 369, Resident 369 stated having diarrhea for a few days, and a big portion of the bed being soiled made her feel like she might have gone so many times. Level of Harm - Minimal harm or Resident 369 also stated having diarrhea this bad was a new thing and felt bad for the staff who had to clean potential for actual harm up.

Residents Affected - Few During a review of Resident 369's clinical record, Skilled Evaluation (written and signed by licensed staff) and Bowel and Bladder Elimination record (completed by assigned CNAs) indicated the following:

- Skilled Evaluation dated 4/6/25 indicated, genitourinary: Urine yellow. Denies urinary complaints., gastrointestinal: Abdomen is flat. Abdomen is non-tender; Bowel sounds present x 4 .Bowel movement appearance: WNL [within normal limits]. Bowel and Bladder Elimination dated 4/6/25 indicated Resident 367 had diarrhea in the day shift.

- Skilled Evaluation dated 4/7/25 indicated, under genitourinary; No urinary complaints .New onset incontinence; No. under gastrointestinal; Abdomen flat, non-tender, Bowel sounds present x 4 [all four quadrants, divides the abdomen into four quadrants], Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/7/25 indicated Resident 369 had diarrhea.

- Skilled Evaluation dated 4/11/25 indicated, genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints., gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4, Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/11/25 indicated Resident 369 had diarrhea.

- Skilled Evaluation dated 4/12/25 indicated genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints., gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4, Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/12/25 indicated Resident 369 had diarrhea.

- Skilled Evaluation dated 4/16/25 indicated genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints., gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4, Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/16/25 indicated Resident 369 had diarrhea.

During an interview on 4/17/25, at 11:20 a.m., with Infection Preventionist (IP), IP stated being unhappy with antibiotics that were used as prophylaxis. IP stated, for urinary tract infections, the following needed to be present before starting antibiotics; symptoms such as fever, burning sensation and signs of infection such as increased heart rate AND a culture and sensitivity to determine what organism and what antibiotic needed to be used, otherwise, if a resident was prescribed an antibiotic that was not going to work, it could mess up their immune system. IP also stated if a resident had more than three episodes of diarrhea, a stool specimen should be sent for testing to prevent spread of a possible infection. IP stated, for Resident 36, a discussion with nursing was done about having to re-do urinalysis and culture, but there was no update as to when this was going to be done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0881 During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, last revised December 2016, the P&P indicated the facility will provide training and education with emphasis on the Level of Harm - Minimal harm or relationship between antibiotic use and gastrointestinal disorders, opportunistic infections like C. difficile and potential for actual harm evolution of drug-resistant pathogens.

Residents Affected - Few During a follow-up interview on 4/17/25, at 3:01 p.m., with IP, IP stated the facility was using McGeer Criteria (a set of clinical and laboratory findings used to define and track infections in long-term care facilities. They help identify potential infections, such as urinary tract infections (UTIs), respiratory tract infections, and skin and soft tissue infections, and monitor their incidence and trends).

A review of Revised McGeer Criteria for LTC (Long Term Care) indicated, for urinary tract infections without

an indwelling catheter, an infection is present when either 1a, 1b or 1c AND 2 are present:

Criteria 1a- acute dysuria, or acute pain, swelling or tenderness on the suprapubic area (the region of the abdomen located directly above the pubic bone)

Criteria 1b-fever or increased white blood cell count AND one or more of the following; suprapubic pain, gross hematuria (visible blood in the urine), new or marked increase in incontinence, urgency and frequency.

Criteria 1c- two or more of the following- suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency and frequency.

AND 2- one of the following must be present; at least 100,000 colony forming units (cfu/ml) of no more than 2 species of microorganisms in a voided urine sample, or at least 100 cfu/ml of any number of organisms in a specimen collected by in-and-out catheter (a temporary tube inserted into the urethra to drain urine from the bladder and then removed).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50474

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 31 residents who occupied 12 multi-bed bedrooms.

This deficient practice had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside.

Findings:

During multiple room observations on 4/14/25 through 4/17/24, there were three residents in Rooms 22, 26, 27, 30, 32, 33, 34, and 35; two residents occupying three-bedroom rooms in rooms [ROOM NUMBER]; and one resident occupying three-bedroom room in room [ROOM NUMBER].

1. room [ROOM NUMBER] measured 11.3 feet by 19 feet which equaled 71.56 square feet per resident.

2. room [ROOM NUMBER] measured 19 feet by 11.4 feet which equaled 72.2 square feet per resident.

3. room [ROOM NUMBER] measured 19.3 feet by 11.4 feet which equaled 73.34 square feet per resident.

4. room [ROOM NUMBER] measured 19.1 feet by 11.3 feet which equaled 71.94 square feet per resident.

5. room [ROOM NUMBER] measured 19.1 feet by 11 feet which equaled 70.03 square feet per resident.

6. room [ROOM NUMBER] measured 19 feet by 11.4 feet which equaled 72.2 square feet per resident.

7. room [ROOM NUMBER] measured 19 feet by 11.4 feet which equaled 72.2 square feet per resident.

8. room [ROOM NUMBER] measured 18.9 feet by 11.4 feet which equaled 71.82 square feet per resident.

9. room [ROOM NUMBER] measured 18.9 feet by 11.4 feet which equaled 71.82 square feet per resident.

10. room [ROOM NUMBER] measured 18.9 feet by 11.3 feet which equaled 71.19 square feet per resident.

11. room [ROOM NUMBER] measured 18.1 feet by 11.7 feet which equaled 70.59 square feet per resident.

12. room [ROOM NUMBER] measured 19.1 feet by 11.3 feet which equaled 71.94 square feet per resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 055292 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055292 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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 0912 During random observations of care and services from 4/14/23 to 4/17/25, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment in the rooms that might Level of Harm - Potential for interfere with resident's care and each resident had adequate personal space and privacy. minimal harm

During an interview on 4/14/25, at 10:45 a.m., with Resident 10, Resident 10 stated the room was small for Residents Affected - Some her. Resident 10 stated she preferred to be in a two-bed room.

During an observation on 4/14/25, at 11:03 a.m., in room [ROOM NUMBER], a Certified Nurse Assistant (CNA) was observed providing care to Resident 25. The privacy and care of Resident 25 were not impacted by shortage of space.

During a concurrent observation and interview on 4/14/25, at 11:21 a.m., with Resident 55, in room [ROOM NUMBER], Resident 55 stated she had no complaints in the room. Resident 55 was observed getting up from the bed with a use of walker with enough space to move around.

There were no negative consequences resulted from decreased space. No safety concerns for residents in

the 12 rooms. The Administrator requested a continuous room waiver for the above residents' rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 055292

F-F812).

During concurrent interview and record review on 4/14/25, at 10:37 a.m., with the DSS, in the DSS office, the DSS revealed she was not a certified Dietary Manager. DSS also stated she took the dietary manager course but failed to complete the course.

During an interview on 4/14/25, at 10:42 a.m., with Registered Dietician (RD), RD stated the facility did not have a qualified Dietary Manager. RD added she worked part time in the facility because she had other facilities to supervise.

During an interview on 4/16/25, at 8:35 a.m., with the Administrator (ADM), ADM confirmed there was no qualified dietary manager. ADM added, RD worked two to three days per week. ADM further added, RD and Nutrition Support Specialist (NSS) shared the responsibility to ensure there was full coverage of qualified Registered Dietician.

During a telephone interview on 4/16/25, at 9:45 a.m., with NSS, NSS stated she had not passed the exam to be a qualified Registered Dietician. NSS also stated she was responsible to oversee the kitchen and staff when RD was not in the facility.

During an interview on 4/16/25, at 11:56 a.m., with DSS, DSS confirmed RD came to the facility part time and NSS came and worked the rest of the week to cover RD's role.

(Cross-reference