Inspection·May 12, 2022

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete quarterly Minimum Data Sets (MDS- an assessment tool used to quid care) timely for eight of ten sampled residents (Residents 10, 11,16, 24, 37, 40, 48, and 49). This failure had the potential to delay care planning and delivery. Residents Affected - Some Findings: During a review of Resident 10's quarterly MDS, the MDS indicated, Assessment Reference Date (ARD the last day to finish the assessment of the resident) 9/24/21, and completed on 10/26/21. During a review of Resident 10's Quarterly MDS, the MDS indicated ARD 12/25/21, completed 1/4/22. During a review of Resident 10's Quarterly MDS, the MDS indicated, ARD 3/27/22, completed on 5/10/22. During a review of Resident 11's Quarterly MDS, the MDS indicated, ARD 3/26/21, no assessment completed. During a review of Resident 11's Quarterly MDS, the MDS indicated, ARD of 5/30/21, completed on 6/23/21. During a review of Resident 16's Quarterly MDS, the MDS indicated, ARD of 3/11/2022, completed on 5/6/2022. During a review of Resident 16's Quarterly MDS, the MDSindicated, ARD of 12/9/21, completed on 2/7/2022. During a review of Resident 16's Quarterly MDS, the MDS indicated, of 9/9/21, completed on 1/21/2022. During a review of Resident 24's Quarterly MDS, the MDS indicated, ARD of 3/9/21, completed on 5/6/22. During a review of Resident 24's Quarterly MDS, the MDS indicated, ARD of 9/6/21, completed on 12/10/21. During a review of Resident 24's Quarterly MDS, the MDS indicated, ARD of 12/7/21, completed 2/7/22. During a review of Resident 37's Quarterly MDS, the MDS indicated, ARD of 8/22/21, completed on 10/14/21. During a review of Resident 37's Quarterly MDS, the MDS indicated, ARD of 11/22/21, completed on 12/29/21. During a review of Resident 37's Quarterly MDS, the MDS indicated, ARD of 2/22/22, completed on 4/26/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 2 of 9 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 055292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 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 0638 During a review of Resident 40's quarterly MDS, the MDS indicated, ARD of 10/3/21, completed on 1/21/2022. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 40's quarterly MDS, the MDS indicated, ARD of 1/3/22, completed 5/3/2022. Residents Affected - Some During a review of Resident 48's Quarterly MDS, the MDS indicated, ARD of 11/17/21, completed 1/17/22. During a review of Resident 48's Quarterly MDS, the MDS indicated, ARD of 2/17/22, completed 4/22/22. During a review of Resident 49's Quarterly MDS, the MDS indicated, ARD of 11/16/21, completed on 2/9/22. During a review of Resident 49's Quarterly MDS, the MDS indicated, ARD of 2/16/22, completed on 4/22/22. During an interview on 5/12/22 at 9:18 a.m., with Director of Nursing (DON), DON stated, Resident 9's annual MDS was submitted late. DON stated, the MDS was required and is a reflection of resident's condition . DON further stated, the MDS is an assessment and could pick up changes in the resident's condition and is used to formulate plan of care. DON also stated, staff have to accurately assess resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 3 of 9 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 055292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the needs for one (Resident 114) of one sampled residents receiving dialysis when the facility did not develop and implement care plan for Resident 114's dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) care. This deficient practice may result in Resident 114's physical, psychosocial and functional needs to go unmet. Findings: A review of Resident 114's admission Record, dated 5/11/22, the Admision Record indicated, Resident 114 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure (condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide). During a record review of Resident 114's doctor's orders, dated 5/11/22, indicated Resident 114 receives dialysis every Mondays, Wednesdays and Fridays at DaVita El [NAME] and has a right chest wall port-a-cath (an implanted device which allows easy access to a patient's veins) used for his dialysis access for his treatments. During a concurrent review of Resident 114's care plan on 5/11/22 at 12:12 p.m. with Director of Nursing (DON), care plan did not ndicate use and care of chest wall port-a-cath. DON stated, there should be a care plan for the use and care of right chest wall port-a-cath. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, the policy indicated, 8. The comprehensive, person-centered care plan will: b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;. A review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, the policy indicated, 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 4 of 9 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 055292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, the facility failed to ensure one (Resident 61), of three sampled residents, received effective oxygen therapy when staff did not assess and monitor Resident 61's use of oxygen. Residents Affected - Few This deficient practice may result in ineffective oxygen therapy. Findings: A review of Resident 61's admission Record, dated 5/11/22, the admission Record indicated, Resident 61 was admitted to the facility on [DATE] with a diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). A review of Resident 61's Medication Review Report, dated 5/11/22, the Medication Review Report indicated, doctor's order on 2/14/2020 to start oxygen at 1 liters per minute (LPM- flow rate) as needed to titrate oxygen saturation above 90% and to wean or discontinue as tolerated by the resident. During a concurrent observation and interview on 5/10/22 at 10:11 a.m., Resident 61 was in bed receiving oxygen by a nasal cannula at 3 LPM. Registered Nurse (RN) 2 confirmed Resident 61 was on oxygen at 3 LPM. RN 2 stated, Resident 61 usually receives oxygen at 2 LPM and does not know why the oxygen is at 3 LPM. RN 2 further stated, Resident 61 is rarely not on oxygen therapy. During a concurrent record review and interview on 5/11/22 at 11:30 a.m. of Resident 61's Medication Administration Record (MAR) for May 2022 with Director of Nursing , the MAR indicated no oxygen assessment. Director of Nursing (DON) stated, staff should document how much oxygen Resident 61 is receiving each time staff checks Resident 61's oxygen saturation the assess the effectiveness of oxygen therapy. A review of the facility document titled, Oxygen Administration, revised October 2010, the Oxygen Administration indicated, After completed the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 3. The rate of oxygen flow, route, and rationale. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 5 of 9 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 055292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care for one (Resident 114) that required dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) when staff did not do a complete assessment before Resident 114's dialysis treatment. Residents Affected - Few This deficient practice resulted in an incomplete assessment of Resident 114's dialysis access site before their dialysis treatment. Findings: A review of the document titled, admission Record, dated 5/11/22, the admission Record indicated, Resident 114 was admitted to the facility on [DATE], with a diagnosis of acute respiratory failure (condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide). During a review of Resident 114's doctor's orders, dated 5/11/22, the doctor's order indicated, Resident 114 receive dialysis treatments every Mondays, Wednesdays and Fridays at DaVita El [NAME] and has a right chest wall port-a-cath (an implanted device which allows easy access to a patient vein) used for his dialysis access during treatments. During a concurrent interview and record review on 5/11/22, at 1:38 p.m. of Resident 114's Dialysis Communication Record on 5/9/22 and 5/11/22 with Director of Nursing (DON), the Dialysis Communication Record indicated, nursing staff did not assess Resident 114's dialysis site before his dialysis treatment. DON acknowledged Resident 114's dialysis access site was not assessed before his dialysis treatments on 5/9/22 and 5/11/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 6 of 9 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 055292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 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 potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff Residents Affected - Few performed hand hygiene between giving medications to two residents (Resident 21 and Resident 119) of 20 sampled residents This failure had the potential to cause or spread infections which can lead to hospitalization for Resident 21 and Resident 119, as well as the rest of the residents in the facility. Findings: 1. During concurrent observation and interview on 05/11/2022, at 4:08 p.m., with Registered Nurse 1 (RN1), in room [ROOM NUMBER], RN1 was observed giving medications to Resident 21. RN1 then went back to the medication cart and prepared medications for Resident 119 without performing hand hygiene. RN1 stated, she should have sanitized her hands between passing medications to different residents because it could spread infections. During an interview on 05/11/2022, at 12:05 p.m., with Director of Staff Development/Infection Preventionist (DSD/IP), DSD/IP stated, her expectation is that all staff perform hand hygiene between giving residents care, coming in and going out of resident rooms, and between glove changes. During a review of the facility handwashing/hand hygiene policy, dated August 2019, the policy indicated, 2. All personnel shall follow the handwashing/handhygiene procedures .7. c. Before preparing or handling medications .m. after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 7 of 9 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 055292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 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 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide 80 square foot of space per resident for 30 residents who occupied 12 multi-bed bedrooms. This condition 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 5/9/22 through 5/12/22, there were three residents in Rooms 22, 24, 27, 31, 33, and 35 and a two residents occupying three-bedroom rooms in Rooms 23,25,26,30,32, and 34. 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. During random observations of care and services from 5/9/22 to 5/12/22, there was sufficient space for the provision of care for the residents in all rooms. There were no heavy equipment in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. During an interview on 5/12/22, at 9:58 a.m., with Resident 11, Resident 11 stated, she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 8 of 9 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 055292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 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 sufficient space in her room. Resident 11 stated, she liked her room. Level of Harm - Potential for minimal harm During an interview on 5/12/22, at 10:31 a.m., Resident 37 stated, she liked her room and had room for her personal belongings. Residents Affected - Some There were no negative consequences resulted from decreased space. No safety concerns or residents in the six rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 9 of 9