Health inspection·December 8, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of thirty-six sampled residents (Residents 24, 25, 56 and 215) had complete and current care plans. This failure had the potential to cause residents to not receive appropriate and adequate care thereby affecting their physical and psychosocial well-being. During a concurrent interview and record review on 12/6/23 at 7:58 a.m. with Director of Nursing (DON), Resident 25's care plans were reviewed. DON stated Res 25 was hospitalized from [DATE] to 10/5/23 and was diagnosed with pneumonia. DON further stated Res 25 received antibiotics from 10/5/23 to 10/7/23. DON stated Resident 25 did not have care plans for pneumonia and antibiotic treatment and without a care plan for antibiotics, the facility would not be able to check if the antibiotic was effective and monitor for side effects. During a concurrent interview and record review at 8:30 a.m. with DON, Resident 24's care plans were reviewed. Resident 24's care plans for Risk for Pain, Risk for decline in ADL (activities of daily living), Risk for Skin Breakdown, Risk for Ineffective Airway Clearance, Limited Activity Involvement, Hypertension, Assisted Fall, and Antibiotic Therapy all had target dates of 11/12/23. DON stated a care plan's target date was 3 months from admission date and then quarterly. DON stated Resident 24's care plans were out of date. During a concurrent interview and record review at 8:31 a.m. with DON, Resident 215's care plans were reviewed. Resident 215's care plans on Risk for Pain, Risk for decline in ADL, Risk for Impaired Nutrition, Risk for Fall, Risk for Skin breakdown, No activity involvement, Hypothyroidism, Osteomyelitis, Antibiotic Therapy, IV Medications, Seizure Disorder, Poor Food Intake, and Actual Impairment to Skin Integrity all had target dates of 11/26/23. DON stated that Resident 215 did not have a care plan on communication. During a concurrent interview and record review at 8:36 a.m. with DON, Resident 56's care plans were reviewed. Resident 56's did not have care plans for foley catheter and pressure ulcer. DON stated the care plans got missed. DON stated the care plans determine goals, necessary interventions, review of treatment and its effectiveness or if needed to make changes. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 2 of 28 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 12/08/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 167) had a physician order to maintain an indwelling catheter (a tube inserted into the bladder that drains urine into a bag outside the body) in place after admission and indication of a medical condition for the use of the indwelling urinary catheter. This deficient practice placed Resident 167 at risk for developing complications related to use of urinary catheters including urinary tract infection. Findings: During observation on 12/4/23 at 10:28 a.m., Resident 167 was observed with a urinary catheter in place. During a review of Resident 167's, admission Record, printed on 12/7/23, the admission record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of bacteremia (the presence of bacteria in the bloodstream) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should and causes them to gradually lose their ability to function). During a review of Resident 167's Physician Orders, there were no orders or indications for use of a urinary catheter. There were no standardized orders for monitoring urinary catheter for prevention of complications in the orders reviewed. During an interview on 12/8/23 at 8:59 a.m. with Director of Nursing (DON), DON stated Resident 167 came from the hospital with a urinary catheter. DON stated they did not have a physician's order for Resident 167 indicating the need of a urinary catheter. DON stated they have an order set that is put in for residents with urinary catheters which was not present for Resident 167. DON verified the orders were started on 12/7/23. DON also stated it is important to have a physician order to understand why an intervention is done. DON stated they can track the progress and monitor if the intervention was successful. DON stated monitoring of urinary catheters is important to prevent complications like infections. During a review of the facility's policy and procedure (P & P), titled, Catheter Care, Urinary, revised in August 2022, the P & P indicated, Catheter evaluation .2. Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use standardized tool for documenting clinical indications for catheter use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 3 of 28 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 12/08/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 show an Interdisciplinary Team meeting was conducted after one sampled resident (Resident 19) had severe weight loss. This failure had the potential to result in inadequate resident care for one resident out of a census of 58. Residents Affected - Few Findings: A record review for Resident 19 showed he was [AGE] years old admitted in January of 2020 and had diagnoses including but not limited to Parkinson's disease, acute kidney failure, amenia, and major depressive disorder. A record review of Resident 19's weight history showed he weighed 178.4 pounds (lbs.) on 10/9/23 and on 10/30/23 he weighed 143.6 lbs., which was a 19.5 percent (%) weight loss in 21 days. Resident 19 was weighed again on 11/2/23 and his weight was 145.6 lbs. which was a 18.4 % weight loss in 24 days. A record review for Resident 19 showed Registered Dietitian Nutritionist (RDN) documented a Nutrition Assessment on 10/31/23. The documentation showed Resident 19 lost 34.8 lbs./19.5% in one month (10/9/23-10/30/23) and was not on a prescribed weight loss program. In an interview on 12/7/23 at 12:05 p.m., RDN stated the facility did not have regular scheduled Interdisciplinary Team (IDT) meetings. RDN stated she could not find a documented IDT/weight variance meeting for Resident 19 after his significant weight loss on 10/30/23. In an interview on 12/7/23 at 12:30 p.m., the DON stated when a resident had a significant weight loss, usually the Assistant Director of Nursing (ADON), the DON, and the Provider discussed what the plan was for the resident. He confirmed this meeting was not documented for Resident 19. During a review of the facility policy and procedure (P&P) titled Weight Assessment and Intervention, revision date of March 2022, the P&P showed the threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. The document also showed weight change is evaluated by the treatment team, and the physician and IDT will identify conditions and medications that may be causing anorexia, weight loss, or increasing risk of weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 4 of 28 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 12/08/2023 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 ensure a care plan for dementia (progressive decline in memory that affects the ability to perform everyday activities) was developed for one of two sampled residents (Resident 167). Residents Affected - Few This failure had the potential for Resident 167 to not receive the appropriate treatment and services needed to meet her dementia care needs. Findings: During a review of Resident 167's admission Record, printed on 12/7/23, the admission Record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and unspecified dementia. During a record review of Resident 167's Minimum Data Set (MDS- an assessment used to guide care), Section C, dated 11/15/23, the MDS showed Resident 167's Brief Interview for Mental Status (BIMScognition assessment) score was 0 out of 15, indicating severely impaired mental status. During a concurrent interview and record review on 12/6/23 at 10:27 a.m., with Director of Nursing (DON), Resident 167's, Care plan, dated 11/11/23, was reviewed. DON stated they do not have a care plan for dementia for Resident 167. During an interview on 12/8/23 at 8:59 a.m. with Director of Nursing (DON), DON stated they did not develop a patient centered care plan for dementia for Resident 167. DON stated it is important to have comprehensive care plan to ensure all the planned interventions to meet the needs of resident is provided. DON also stated the risk of not having a care plan is that any appropriate changes to resident's plan of care will be missed. During a review of the facility's policy and procedure (P&P) titled, Dementia- Clinical Protocol, revised in [DATE], the P&P indicated, Treatment /Management. 1. For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life .Monitoring and Follow- Up .2. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 5 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, and full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. The lack of qualified, full time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 58 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: 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). Review of the job description titled Dietary Services Director signed by the Dietary Services Manager (DSM) on 10/10/23, the primary purpose of the job position was to assist the Dietitian in planning, organizing, developing, and directing the overall operation of the Food Services Department in accordance with current Federal, State, and local standards, guidelines and regulations governing the facility, to assure quality nutritional services are provided on a daily basis and that the Food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 6 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Services Department is maintained in a clean, safe, and sanitary manner. The job description also showed the specific requirements for the position included must be registered as a Food Service Director in the State. In an interview on 12/04/23 at 9:22 a.m., DSM stated she was the supervisor for the kitchen. Residents Affected - Many In an interview on 12/4/23 at 12:34 a.m., Registered Dietitian Nutritionist (RDN) stated she worked at the facility part time, twice a week for 16 hours total per week. In an interview on 12/8/23 at 10:30 a.m., DSM stated she was currently working on her qualifications to because a Certified Dietary Manager (CDM). She confirmed she did not have qualifications to qualify her for the full-time supervisor of Food and Nutrition Services. In an interview on 12/8/23 at 11:16 a.m., the Administrator (ADM) confirmed DSM was not qualified for the Dietary Services Director position per the California Code, Health, and Safety Code - HSC § 1265.4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 7 of 28 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 12/08/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility document review, the facility failed to ensure kitchen staff were competent regarding job duties when: Residents Affected - Many 1. A cook did not know the appropriate method for manually cleaning soiled utensils and equipment using the 3-compartment sink. 2. A diet aide did not know the appropriate procedures for testing the strength of the sanitizer solution used for sanitizing kitchen surfaces. 3. A diet aide did not demonstrate appropriate procedures for testing the sanitizer in the dish machine. These failures had the potential to result in contamination of kitchen equipment and/or utensils leading to illness caused by pathogens (harmful organisms) for 58 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 12/05/23 at 10:35 a.m. with [NAME] 2, [NAME] 2 stood by the 3-compartment sink and described the process for cleaning soiled utensils/equipment in the sink. He stated the first sink was filled with water only, the second sink was filled with water and soap, and the third sink was filled with sanitizer. [NAME] 2 stated the water in all the sinks had to be room temperature and the equipment/utensils had to be submerged in the sanitizer for no less than five minutes. During an interview on 12/05/23 at 1:45 p.m. with the Dietary Services Manager (DSM), DSM stated that three compartment sinks should be in the following order of wash, rinse and sanitize. She stated the sanitizer used was the acid-based sanitizer. A review of the manufacturer's instruction for the acid-based solution, which was located on the inside of the kitchen's chemical room door, titled, [Brand Name] Sink and Surface Cleaner Sanitizer indicated the sanitizer could be used in a 3-compartment sink and immersed items in the sanitizer until thoroughly wet for at least 60 seconds. Review of the facility's Policy and Procedure (P&P) titled, Sanitation and Infection Control Warewashing (Handwashing Method), dated 2018, the P&P indicated using the 3-compartment sink, the first sink was for washing and the sink is filled with a detergent solution and the water is to be at least 100 degrees Fahrenheit (F); the second sink is for rinsing and is filled with clean hot water; and the third sink is for the sanitizer solution. 2. During a concurrent observation and interview on 12/05/23 at 10:39 a.m. with Diet Aide 1 (DA 1), DA 1 stated she was responsible for filling red buckets with sanitizer and checking the strength of the sanitizer. DA 1 demonstrated how she checked the sanitizer strength by filling a red bucket with an acid-based sanitizer solution dispensed from a hose located inside the kitchen's chemical closet. DA 1 picked up a test strip bottle used for testing chlorine sanitizer solutions from the drawer. DSM, who was nearby stated wrong one. DA 1 asked which one, then picked up a test strip bottle for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 8 of 28 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 12/08/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the acid-based sanitizer. DA 1 proceeded to test the sanitizer strength by placing the test strip into the solution for eight (8) seconds. When asked, DA 1 stated, she held the strip in the solution for 10 seconds and was supposed to hold it in the solution for 10 seconds. During an interview on 12/05/23 at 10:42 AM with DSM, DSM stated test strips should be dipped and held in the acid-based solution for five seconds. During a review of the manufacturer's instruction for the acid-based solution which were located on the inside of the kitchen's chemical room door, titled, [Brand Name] Sink and Surface Cleaner Sanitizer, the instructions indicated, Dip strip for 5 seconds in test solution. 3. During a concurrent observation and interview on 10/05/23 at 10:25 a.m. with DA 1, in the kitchen, DA 1 was cleaning dishes using the dish machine. She stated she was responsible for checking the sanitizer strength for the sanitizer used in the dish machine. DA 1 demonstrated the process for testing the dish-machine sanitizer concentration. After the dish machine rinse cycle was completed, DA 1 opened the door to the dish machine and touched a chlorine sanitizer test strip to the surface of a plate. She compared test strip to the color chart located inside the test strip container. The color of the test strip was dark purple. DA 1 said the test strip showed the sanitizer strength was 200 parts per million (ppm) and was not good and the sanitizer was too strong. DA 1 stated she should report to her supervisor if the sanitizer strength was too strong. After testing the sanitizer strength, DA 1 continued to clean dishes using the dish machine and did not report to her supervisor, who was in the kitchen, that the sanitizer strength of the dish machine was too strong. During an interview on 12/05/23 at 10:39 a.m. with DSM, DSM stated 200 ppm reading was out of range. During a review of facility's P&P titled Sanitation and Infection Control Dishwashing Procedures (Dish machine), dated 2018, the P&P indicated, Use a chemical sanitizing rinse to achieve and maintain 50-100 PPM of chlorine at dish surface. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 9 of 28 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 12/08/2023 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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure: Residents Affected - Many 1. the menu met the nutritional needs of the residents; 2. there was a menu for a vegetarian diet; and 3. portions for diets provided matched what was indicated in the diet manual. These failures had the potential for residents to receive meals containing nutrients at levels not appropriate for their prescribed diet leading to food related medical complications for 58 residents who received food from the kitchen. Findings: 1. Per the National Institute of Health, Nutrient Recommendations: Dietary Reference Intake (DRI) are documents issued by the Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and sex, include Recommended Dietary Allowance (RDA): the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals and often used to plan nutritionally adequate diets for individuals; and Adequate Intake (AI): Intake at this level is assumed to ensure nutritional adequacy and is established when evidence is insufficient to develop an RDA. The following lists the recommended level of DRIs that were not met based on the hospital's nutrient analysis. Ranges are based on age and gender. Review of the daily nutrient analysis spreadsheet of the menu from 10/1/23 - 12/8/23, showed 14 nutrients and the corresponding amounts provided by the menu for each meal. The analysis showed values for seven nutrients with RDAs (Protein, Carbohydrate, Calcium, Iron, Phosphorus, Vitamin A, Vitamin C) out of 19 nutrients that have RDAs, and one nutrient with an AI (Potassium) out of six nutrients that have AIs. The nutrients listed were not a complete list of nutrients for which RDA and AI information are available. In addition, the nutrient analysis only provided information for the Regular diet and not the therapeutic diets. Review of resident tray tickets used for lunch on 12/4/23, showed residents were prescribed a variety of diets including Regular, Consistent Carbohydrate (a diet typically prescribed for a person with diabetes or issues with controlling blood sugar), Small Portion, Mechanical Soft (a diet where the food is mechanically altered to a texture that is easy to chew), Pureed (a diet where the food is mechanically altered to a smooth texture and thick enough to hold shape), Renal (a diet typically prescribed for a person with kidney disease), and Vegetarian (no meat). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 10 of 28 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 12/08/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the diet spreadsheet titled Diet Extensions, dated 12/4/23, showed the food sizes and portions for therapeutic diets were not always the same as the Regular diet, so the amount of nutrients in a therapeutic diet would differ from the amount in the Regular diet. For instance, for lunch a Regular diet received a 3 inch by 2 inch piece of spice cake and the CCHO and Renal diet received a half piece of cake. Also, the Regular diet received a number 8 scoop (about 4 fluid ounces) of baked sweet potato and the Renal diet received low sodium rice or pasta. In an interview with Registered Dietitian Nutritionist (RDN) on 12/5/23 at 9:04 a.m., RDN confirmed there was a nutrient analysis for the Regular diet but not for any of the therapeutic diets offered at the facility. She also confirmed for the Regular diet, the nutrient analysis did not include all available Dietary Reference Intake (RDAs and AIs) information. In an interview on 12/5/23 at 1:50 p.m., RDN confirmed she approved the menu, but she did not make sure the menu met the nutrient recommendations for the facility demographics. Review of the daily nutrient analysis of the menu from 10/1/23 - 12/8/23 (69 days), showed the daily calories were under 2000 kcals on 47 days and went as low as 1476 kcals on two of the days. In an interview on 12/6/23 at 12:05 p.m., RDN stated the diet manual used at the facility was not from the same company who made the menus. She confirmed the diet manual showed the Regular diet should provide 2000-2400 kcals (kilocalories) per day. She confirmed the calories shown on the nutrient analysis for the Regular diet were lower than what was recommended in the diet manual. She stated she did not think the menu according to the nutrient analysis provided enough calories to meet the estimated caloric needs of residents. In an interview on 12/7/23 at 12:12 p.m., RDN stated when she assessed whether residents' food intake met their estimated caloric needs, she used 2100-2300 kcals as the baseline for kcals provided by the daily menu. 2. An observation of tray line food service and concurrent interview with [NAME] 3 on 12/4/23 at 11:40 a.m., showed a food tray was prepared for Resident 57. Resident 57's tray ticket showed his diet was a Regular texture, Consistent Carbohydrate, No added Salt, Vegetarian. [NAME] 3 stated the vegetarian entrée for lunch today was grilled cheese. It was identified the grilled cheese sandwich provided to Resident 57 was not of equal nutrient content to the regular entrée served (Cross-reference F803). A record review for Resident 57 showed a diet order prescribed by his primary physician was placed on 8/24/23 and included Vegetarian. Review of the daily menu dated 12/04/23, showed 10 diets listed with corresponding food items and portion sizes to serve for each diet. A Vegetarian diet was not listed on the menu to show what a resident on a Vegetarian diet should receive for meals. In an interview on 12/5/23 at 12:40 p.m., Resident 57 stated he received repeated food daily such as salads and vegetables. He stated he would love to try other food options. He stated there was not a menu that he could look at, for his Vegetarian diet. In an interview with RDN on 12/5/23 at 1:50 p.m., she stated there was not a Vegetarian or Plant Based (no animal products) menu available because we don't get a lot of vegetarians. RDN confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 11 of 28 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 12/08/2023 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 0803 Vegetarian diet was a Doctor ordered diet. Level of Harm - Minimal harm or potential for actual harm Review of the Diet Manual Rehabilitation, Residential and Long Term Care Facilities, dated 2018, showed a Vegetarian diet was included as a recognized diet and provided information about the diet such as the approximate macronutrient (nutrients that are needed in larger quantities in the diet) and calorie composition the diet was to provide. Residents Affected - Many 3. During an observation of tray line food service and a concurrent interview with DSM on 12/04/23 at 11:40 a.m., showed residents on physician prescribed small portion and large portion diets. For the small portion diets, the portion sizes were the same as the regular except for the sweet potatoes, which were a small portion. Also, for the large portion diets, the portion sizes were the same as the Regular diet except for a larger portion of sweet potatoes were served. DSM confirmed small portion diets received a smaller portion of the carbohydrate food (starchy foods such as potatoes, pasta, rice) item and the large portion diets received double the amount of the carbohydrate food item. She stated the rest of the food portions were the same as the Regular diet. Review of the Diet Manual Rehabilitation, Residential and Long Term Care Facilities, dated 2018, showed Large Portion diets were to receive increased ¼ to ½ cup increments for the entrée and starch items. The diet manual also showed for Small Portion diets, food items should be reduced by ¼ cup increments for entrees and starch items. In an interview on 12/6/23 at 2:5 p.m., RDN stated the usual portions served on tray line for small and double portions were half the amount of carbohydrate for small portions and for large portions double the amount of carbohydrate and vegetables. RDN confirmed the diet manual was not followed for large and small portion diets. Review of the facility policy and procedure titled Food Preparation Subject: Portion Control, dated 2018, showed small portions and large portions may be given to residents per physician order. For small portions, unless otherwise stated on the menu, food items should be reduced by ¼ cup increments for entrees, starch, and vegetables. For large portions, unless otherwise stated on the menu, portion sizes should be increased in ¼ cup increments for entrees, starch, and vegetables. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 12 of 28 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 12/08/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to serve food that was palatable when food was bland (lacked flavor). Residents Affected - Many This failure had the potential to negatively impact the residents' dining experience which may result in poor dietary intake compromising the health and nutritional status of 58 residents who received food from the kitchen. Findings: During an interview on 12/04/23 at 10:45 a.m. with Resident 16, Resident 16 stated the facility's food was lacking in taste and beans were very plain. During a review of daily menu, dated 12/04/23, the lunch menu indicated green beans were served for all diets. During a concurrent observation and interview on 10/04/23 at 12:50 p.m. with Registered Dietitian Nutritionist (RDN), a test tray was conducted. The test tray contained the same regular textured and pureed food served to residents for lunch. The food was tasted by three surveyors and the RDN. All the surveyors and the RDN agreed the green beans for both regular and pureed were lacking flavor. During a review of daily menu dated 12/05/23, the lunch menu indicated items served included, but were not limited to, smothered cube steak, brown rice with gravy, and California blend (mixed vegetables). During an interview on 12/05/23 at 11:40 a.m. with [NAME] 2, [NAME] 2 stated he never added salt to the food when he cooked it. During a concurrent interview and record review on 12/05/23 at 11:43 a.m. with RDN, the undated recipe titled Brown [NAME] with Gravy was reviewed and showed salt was an ingredient. RDN confirmed the recipe used salt. She said [NAME] 2 should follow the recipe when preparing food and should add salt if the recipe called for salt. During a concurrent observation and interview on 12/05/23 at 11:50 a.m. with RDN, a test tray was conducted. The tray consisted of the same regular and pureed food served to residents. Three surveyors and the RDN tasted the food. The surveyors and the RDN agreed the regular and pureed mixed vegetables, and the regular and pureed rice, lacked flavor. RDN stated the regular and pureed rice and vegetables were bland and could use salt. During a review of facility's policy and procedure (P&P) titled Food Preparation .Tasting of Food Prior to Serving, dated 2018, the P&P indicated, Cooks are required to taste all food prior to serving to ensure adequate seasoning and quality .5. Remember, if the food does not taste good, the residents/patients will not eat it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 13 of 28 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 12/08/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and facility document review the facility failed to ensure pureed food was the appropriate consistency. This failure had the potential for eight residents on pureed diet to aspirate (drawing food into the lungs) and/or negatively impact the residents' dining experience resulting in poor food intake compromising their nutritional status out of facility census of 58. Findings: Review of the Diet Manual Rehabilitation, Residential and Long Term Care Facilities, dated 2018, showed the pureed diet should be smooth and the consistency of pudding. During a review of facility's policy and procedure (P&P) titled Food Preparation .Food Cookery, dated 2018, the P&P indicated, Pureed Food Preparation .Pureed food should be prepared to the consistency and thickness of mashed potatoes rather than a gravy or watery texture. Review of the daily menu, dated 12/04/23, showed the lunch menu included a pureed diet which received pureed pork with apples, pureed sweet potato, and pureed green beans. During an observation on 12/04/23 at 12:50 p.m. with Registered Dietitian Nutritionist (RDN), a test tray was conducted. The test tray contained the same pureed food served to residents for lunch. The plate which contained pureed hot food showed the pureed pork, sweet potato, and green beans were flat and spread out on the plate, so the foods ran into each other. Review of the daily menu, dated 12/05/23, the lunch menu showed the pureed diet received pureed smothered cube steak, pureed brown rice with gravy, pureed California blend mixed vegetables. During an observation on 12/05/23 at 11:45 a.m. in the kitchen, [NAME] 2 pureed cooked rice by adding scoops of rice to a blender. Then he added water from the tap without measuring the water. Before starting to blend the rice and water, he added more water into the blender. Then he blended the water and rice. When he was finished blending, the mixture was thin and pourable. [NAME] 2 poured the pureed rice into a metal container and placed it on the tray line to serve. During a concurrent observation and interview on 12/05/23 at 11:50 a.m. with RDN, a test tray was conducted. The test tray contained the same pureed food served to residents for lunch. The pureed smothered cube steak, pureed brown rice with gravy, and pureed California blend mixed vegetables were runny and spread out on the plate, so the different food items came into contact with each other. RDN stated when the staff pureed food, the food should be blended first, then water added gradually if needed. In an interview on 12/6/23 at 2:05 p.m., RDN confirmed the diet manual showed the pureed food should be pudding thick. She stated the pureed food served was thinner than pudding thick. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 14 of 28 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 12/08/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and facility document review, the facility failed to: 1. Provide an alternate vegetarian entrée of similar nutritive value to the regular entrée for one non-sampled resident (Resident 57). 2. Ensure peanut butter and jelly sandwiches offered as an alternate entrée were of similar nutritive value to the regular entrée. These failures had the potential to result in a decreased nutrient intake as indicated by the planned menu for 29 residents who received Regular textured food. Findings: 1. A review of Resident 57's admission Record, printed 12/08/23, showed Resident 57 was originally admitted in August 2023 with diagnoses of anemia (lack of red blood cells), diabetes (too much sugar in the blood), depression, and muscle weakness. A review of Resident 57's Order Details, dated 08/24/23, showed Resident 57 had an order for a vegetarian diet placed by a primary care physician. During a review of Resident 57's lunch tray ticket, dated 12/04/23, the ticket showed Resident 57 was on a vegetarian diet. During a review of the facility's menu spreadsheet, titled Diet Extensions, dated 12/04/23, the menu spreadsheet indicated the regular entrée for lunch was three ounces (oz) of Roasted Pork with Apples. A vegetarian diet was not listed on the menu. During an observation on 12/04/23 at 11:40 a.m., [NAME] 3 prepared a grilled cheese sandwich and placed it on the tray for Resident 57. She stated the grilled cheese sandwich was the vegetarian entrée for lunch that day. She stated she prepared the sandwich using two slices of cheese. A review of the undated recipe for Roasted Pork with Apples, showed a 3 oz serving contained 25 grams (gm) of protein. On 12/5/23 at 9:06 a.m., an observation showed a large package of sliced Pasteurized Process Swiss and American Cheese stored inside a reach in refrigerator in the kitchen. The nutrition facts on the package showed a slice of cheese was equivalent to three gm of protein. During an interview on 12/05/23 at 1:45 p.m. with Dietary Supervisor Manager (DSM) and Registered Dietitian Nutritionist (RDN), DSM confirmed two slices of processed Swiss American cheese was used to prepare the grilled cheese sandwiches. DSM confirmed the grilled cheese was a substitute for the Roasted Pork entrée for Resident 57's lunch on 12/4/23. During an interview on 12/06/23 at 12:05 p.m. with RDN, RDN stated for the grilled cheese sandwich, 2 slices of cheese which contained 6 grams of protein total, was not an adequate substitute for 3 ounces of meat or 25 grams of protein contained in one serving of the Roasted Pork entrée. During a review of facility's Policy and Procedure (P&P), titled Menus .Menu Alternate dated 2018, the P&P indicated, Menu alternates will be of similar nutritive value as the original menu item . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 15 of 28 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 12/08/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview with [NAME] 1 in the kitchen on 12/05/23 at 10:39 a.m., [NAME] 1 prepared peanut butter and jelly sandwiches. [NAME] 1 spread peanut butter and jelly on slices of white bread. [NAME] 1 stated that she prepared the peanut butter and jelly sandwiches which could be used for substitutes if residents disliked their meal. [NAME] 1 further stated that she did not measure the peanut butter and just spread a little, not too much on the bread. Residents Affected - Many During an interview on 12/05/23 at 1:45 p.m. with DSM and RDN, DSM confirmed the peanut butter and jelly sandwich could be a substitute for an entrée. DSM stated that no other food items were added when the peanut butter and jelly sandwich was served as a substitute. RDN confirmed other food items were not added when peanut butter and jelly was served as a substitute, to make the substitute equal in nutritive value to the entrée served. DSM and RDN both stated they did not know if there was a recipe for peanut butter and jelly sandwiches. During a review of Peanut Butter and Jam Sandwich recipe, it indicated to spread 2 tablespoons peanut butter on each peanut butter and jelly sandwich. Each half slice of sandwich had an equivalent eight gm of protein. During an interview on 12/06/23 at 12:05 p.m., RDN stated she did not think that peanut butter and jelly sandwich recipe provided adequate protein for an entree substitute. During a review of facility's Policy and Procedure (P&P) titled, Menus .Menu Alternate, dated 2018, the P&P indicated, Menu alternates will be of similar nutritive value as the original menu item. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 16 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when the following was noted: Residents Affected - Many 1. A 10-pound roll of ground beef and a 10-pound package of sausage were not thawed safely. 2. A juice dispenser was not clean. 3. A can opener was not clean. 4. Three cutting boards were not in a good condition and were not clean. 5. Dry food was not stored at least six inches off the floor. 6. Three pans were in poor condition. 7. A lowerator (plate warmer) was not clean. 8. A fan mounted to the wall inside the kitchen was not clean. 9. A vent inside the dry food storage closet was not clean. 10. The floor of three food storage/ supply closets located in the hallway, outside of the kitchen, had a rough, crumbling surface where transition strips (a long strip made of metal, wood, or other material, with rounded edges, used to bridge two floors together) were missing. 11. The handwashing sink was used for another purpose other than handwashing. 12. Expired test strips were available and used to test sanitizer concentrations for the dish machine and surface sanitizer. These failures placed 58 residents who received food from the kitchen at risk for food borne illnesses. Findings: 1. During an observation on 12/05/23 at 9:03 a.m. in the kitchen, a 10-pound roll of ground beef was thawing in a bucket filled with standing water in the 3-compartment sink. During an interview on 12/05/23 at 10:14 a.m. with [NAME] 2, he confirmed the bag of ground beef was being thawed. He stated the water should be running into the bucket with the ground beef. During a concurrent observation and interview on 12/05/23 at 10:16 a.m. with [NAME] 1., a 10-pound package of sausage was thawing in bucket under a running water in the three compartment sink. The end of the sausage package was exposed above the surface of water so at least two sausages were not submerged in the water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 17 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 12/05/23 at 10:19 a.m., Dietary Services Manager (DSM) stated the sausage bag did not need to be fully submerged in the water. During a review of facility's policy and procedure (P&P) titled, Food Preparation .Food Defrosting Methods, dated 2018, the P&P indicated thawing food at room temperature is not acceptable. Meat may be defrosted by placing under cold running water under 70 degrees F (Fahrenheit) for no more than 2 hours. According to U.S. Food and Drug Administration Federal Food Code 2022, when thawing Time/Temperature Control for Safety (TCS) food (food more likely to grow harmful pathogens if not stored safely) in water, it is to be submerged completely under running water. 2. During the initial kitchen tour on 12/04/23 at 9:54 a.m., boxes of concentrated juices were connected to hoses which then connected to a bar gun dispenser. A plastic connector which connected the concentrated orange juice bag to the hose, had brown residue covering the surface and was sticky when touched. During an interview on 12/06/23 at 10:10 a.m. with DSM, DSM stated Dietary Aide (DA) 1 was one staff responsible for cleaning the juice dispenser gun. She stated staff did not clean the hose or connectors. She stated the juice machine was cleaned by diet aides three times a day. During an observation in the kitchen and concurrent interview with DA 1 on 12/06/23 at 10:12 a.m., DA 1 stated that she cleaned the juice dispenser gun during her shift. DA 1 demonstrated how she cleaned the dispenser gun. She removed a black plastic nozzle, so the surface of the diffuser (a part of the dispenser gun that spreads a liquid out to separate or slow down the speed of the flow of the liquid) and O-ring (a rubber ring that helps seal two parts together when the parts are connected) were visible. There was an accumulation of a moist, dark pink residue and clustered spots of light pink residue on the surface of the diffuser and O-ring. As the observation and interview continued on 12/6/23 which started at 10:12 a.m., DA 1 proceeded to demonstrate the cleaning process. She filled a metal container with a mixture of water and acid-based sanitizer dispensed from a hose in the chemical closet. It was noted DA 1 did not test the strength of the sanitizer solution. She placed the black plastic nozzle inside the solution and placed just the tip of the dispenser gun (the diffuser and O-ring) in the solution. DA 1 had difficulty keeping the dispenser gun inside the solution in the metal container, as it kept falling out. DA 1 stated she soaked the dispenser gun and black plastic nozzle in the solution for 30 minutes then rinse the pieces with water after. As the observation and interview continued on 12/6/23 which started at 10:12 a.m., DA 1 then demonstrated the rinsing process of the dispenser gun. DA 1 emptied the solution from the metal container, then filled it with water from the handwashing sink. DA 1 placed the tip of the dispenser gun in the water, she stated she soaked both nozzle and dispenser gun in water for 15 minutes then she would reinstall the black plastic nozzle to the dispenser gun. During an interview on 12/06/23 at 10:17 a.m. with DSM, DSM stated to clean the juice dispenser gun, the staff were to use warm water. She also stated the black plastic nozzle was to be removed to clean the dispenser gun and staff had to make sure the nozzle and diffuser were clean. DSM stated the whole dispenser gun should be fully submerged in warm water, not just the tip. DSM further confirmed the orange juice connector was sticky and dirty, she did not know who cleaned the connectors or the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 18 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hoses, but she said the juice dispenser company provided services every 4-5 months. DSM also stated staff did not have instructions to follow on how to clean the dispenser gun or other parts of the machine. During an interview on 12/06/23 at 10:45 a.m. a photo of the dispenser gun diffuser and O-ring from when it was observed earlier in the day at 10:12 a.m., was showed to RDN. RDN stated there was a build-up and some sort of substance accumulation on the diffuser and it did not appear it was cleaned three times a day. In an interview on 12/6/23 at 12:05 p.m., RDN stated she was concerned staff were not cleaning the juice machine because she never saw them cleaning it, so she gave instructions to DA 1 on how to clean the machine. RDN stated she did not have instructions on how to clean the machine. On 12/7/23 at 2:05 p.m., RDN provided an undated document titled Weekly Cleaning Guide for Bar Gun Systems. RDN confirmed these were cleaning instructions from the company who serviced the juice machine but were not the juice machine/juice dispenser gun manufacturer's cleaning instructions. The instructions provided by the juice machine cleaning company showed to unhook the plastic connectors from the juice boxes and soak the connectors in warm water for one minute and ensure all juice residues were dissolved before reconnecting the connectors. The instructions also showed to remove the black plastic nozzle from the bar gun and clean with warm, soapy water. Then set aside to dry. The instructions then showed to wipe off any juice build-up accumulated on the nozzle of the bar gun, fill a container with warm water and allow the bar gun to soak for five minutes. Then reinstall. RDN stated she would look for the manufacturer's cleaning instructions. Review of the document titled [Manufacturer's Name] Post-Mix Beverage Dispenser, revision date of 4/9/21, provided by RDN as the manufacturer's manual for the juice machine dispenser gun, showed directions on preparing the chloromelamine sanitizer (a chlorine based sanitizer) solution to use for sanitizing the juice gun. The directions then showed how to clean the sheathing (hoses) for the juice machine using the sanitizer solution. The directions showed to clean the juice machine nozzle, to remove the black nozzle and place in the sanitizer solution for two minutes, and scrub with a brush to remove any build-up. Then immerse a brush in the sanitizer solution and scrub the diffuser with the brush to remove any build-up. Then the air-dry the nozzle and the diffuser. During a concurrent interview and manufacturer's cleaning instruction review on 12/08/23 at 9:40 a.m. RDN confirmed kitchen staff were not using the sanitizer recommended by the juice machine dispenser gun to clean the dispenser gun. RDN also confirmed the staff should clean the juice machine connectors and sheathing/hoses as shown in the manufacturer's instructions. During a concurrent interview and review of the Daily Cleaning Schedule, dated November 2023 and December 2023, on 12/8/23 at 9:50 a.m., the cleaning schedule showed boxes to initial for each day of the month, for various pieces of equipment. Many boxes for various pieces of equipment were filled with initials. However, all the boxes coinciding with the juice machine for each day of the month in November were not initialed. For the month of December two boxes for December 1 and 2 were initialed by the juice machine but boxes for December 3, 4, 5, 6, 7, and 8 were not initialed. It was also noted there were no boxes to initial to show the juice machine was cleaned three times per day as there was only one box per day to initial. DSM confirmed staff were not signing off on cleaning the juice machine. DSM stated when a piece of equipment was cleaned, the staff should initial the cleaning schedule. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 19 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility's P&P titled, Sanitation and Infection Control Subject: Cleaning Schedules, dated 2018, showed cleaning schedules will be developed and enforced by the Director of Food and Nutrition Services. Schedules should indicate the frequency of cleaning with tasks and designated to specific positions. Employees will initial on the schedule when designated tasks are completed. All staff will be trained to use the cleaning schedules/procedures. Cleaning procedures should specify products to be used. Cleaning solutions must be used in proper concentration and dilution. The Director of Food and Nutrition Services should routinely check cleaning schedules . According to U.S. Food and Drug Administration Federal Food Code 2022, equipment food-contact surfaces and utensils shall be clean to sight and touch. In addition, equipment nonfood-contact surfaces of equipment shall be kept free of an accumulation of food residue and other debris. 3. During a concurrent observation in the kitchen and interview with DSM on 12/04/23 at 9:50 a.m., the industrial can opener stored in a holder mounted on a table had a brown residue build-up on the can opener's blade and on the can opener holder mounted to the table. When wiped with a paper towel, a sticky brown substance transferred to the paper towel. In addition, the can opener shaft (handle) was sticky to the touch. DSM stated the can opener was dirty, it should be cleaned after each use. During a review of the facility's P&P titled, Sanitation and Infection Control .Cleaning Small Appliances/Equipment, dated 2018, the P&P indicated equipment will be cleaned and sanitized to prevent food borne illness .2. Can Openers are to be cleaned after each use and sanitized daily. 4. During a concurrent observation and interview on 12/05/23 at 11:07 a.m. with RDN, three randomly selected cutting boards from a clean storage rack, located on a preparation table, had a significant number of scratches on the cutting surface so the surfaces were rough to the touch. There were also visible black and brown residue deposits on the cutting surfaces. One cutting board was sticky when touched. RDN Confirmed the cutting boards were scratched and had visible residue. Review of facility's P&P titled, Sanitation and Infection Control .Cleaning Small Appliances/Equipment, dated 2018, showed cutting boards will be clean and sanitized after each use. According to U.S. Food and Drug Administration Federal Food Code 2022, Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. In addition, multiuse food-contact surfaces are to be smooth and free from inclusions, pits, and similar imperfections. 5. During a concurrent observation and interview with DSM on 12/04/23 at 10:05 a.m., showed dry food stored in a closet in the hallway outside of the kitchen. The bottom shelf was approximately 2 inches from the floor and a case of vanilla wafers, a case of tea bags, and a case of hot chocolate packages were stored on the bottom shelf. DSM stated the food should be stored six inches above the floor. During a review of the facility's P&P titled, Sanitation and Infection Control .Canned and Dry Goods Storage, dated 2018, showed All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly .5. Food and supplies should also be stored six inches off the floor. 6. During the initial tour of the kitchen on 12/04/23 at 9:45 a.m., a large pan stored via a hanging storage system above the 3-compartment sink, had a dry, black residue build-up on the food-contact surface. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 20 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An observation on 12/4/23 at 11:40 a.m., showed [NAME] 3 prepared food on the stove using two pans. The cooking surface of the pans were significantly scratched. During a concurrent observation and interview on 12/05/23 at 9:05 a.m. with Registered Dietitian Nutritionist (RDN), two non-stick pans which appeared to be the same pans [NAME] 3 used to prepare food for lunch on 12/4/23 were stored on a shelf underneath the tray line counter. The cooking surface of these two non-stick pans were noted to have significant scratches, and pieces of the non-stick coating were peeled off. The three pans then were examined with RDN, including the large pan with black residue build-up observed hanging above the 3-compartment sink on 12/4/23. RDN confirmed there was black residue build-up on the large pan and the two smaller pans were scratched. According to U.S. Food and Drug Administration Federal Food Code 2022, multiuse food-contact surfaces are to be smooth and free from inclusions, pits, and similar imperfections. In addition, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. 7. During a concurrent observation and interview on 12/04/23 at 9:56 a.m. with DSM, in the kitchen, there was a lowerator located on one side of the tray line counter. There was what resembled food crumbs and other debris covering the inside bottom surface of the lowerator. DS stated the lowerator was dirty because it was difficult to reach the bottom. According to U.S. Food and Drug Administration Federal Food Code 2022, Equipment Food-NonFood-Contact Surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. 8. During an initial tour of the kitchen on 12/04/23 at 9:50 a.m., a large fan was mounted to the wall and facing the dish machine. The fan's plate guard was covered with a gray, fuzzy substance. During a concurrent observation and interview on 12/07/23 at 8:55 a.m. with the Maintenance Director (MD), MD stated the fan in the kitchen was dusty. He also stated housekeeping staff was responsible for cleaning the fan but there was no documentation to show when it was last done. He stated there was not a written schedule that included fan cleaning. He stated he did not think the fan was used. According to U.S. Food and Drug Administration Federal Food Code 2022, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust. In addition, the premises shall be free of items that are unnecessary to the operation or maintenance of the establishment such as equipment that is nonfunctional or no longer in use. 9. During a concurrent observation and interview on 12/04/23 at 10:05 a.m. with DSM, in the dry food storage room located in the hallway outside the kitchen, a vent in the ceiling, directly above shelving holding dry food goods, had a gray, fuzzy build-up on the surface. DSM stated the vent was not clean and dirty. DSM also stated that maintenance was responsible for cleaning the vents. During a concurrent observation and interview on 12/07/23 at 8:15 a.m. with MD, in the dry food storage room, MD stated the vent was dusty and needed to be cleaned. MD stated there was no documentation to show when the vent was last cleaned and there was not a written schedule that included vent cleaning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 21 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many According to U.S. Food and Drug Administration Federal Food Code 2022, Maintenance and Operation .Physical facilities shall be cleaned as often as necessary to keep them clean. 10. During a concurrent observation and interview on 12/04/23 at 10:05 a.m. with DSM, there were three storage areas used for kitchen supplies located in the hallway outside of the kitchen. The first storage closet contained dry food goods, the second contained emergency food supplies, and the third contained single-use food service items. All three areas had a long gap in the floor between the hallway floor and the inside closet floor. At the gaps, the edges of the flooring were cracked, and the surface was not smooth. There were pieces of debris collected in the gaps. During a concurrent observation and interview on 12/07/23 at 8:15 a.m. with MD, MD stated the three storage room floors were missing transition strips (a long strip made of metal, wood, or other material, with rounded edges, used to bridge two floors together) between the hallway floor and the closet floors. According to U.S. Food and Drug Administration Federal Food Code 2022, floors and floor coverings are to be designed, constructed, and installed so they are smooth and can be easily cleaned. In addition, physical facilities shall be maintained in good repair. 11. During an observation on 12/06/23 at 10:12 a.m. with DA 1, DA 1 demonstrated how she cleaned the juice machine. During the demonstration, she emptied sanitizer solution from a metal container and filled it with water from the handwashing sink. Then she proceeded to clean the juice machine using the water in the metal container from the handwashing sink. During an interview on 12/06/23 at 10:17 a.m. with DSM, DSM stated that DA 1 should not use the water from the handwashing sink, that area was only intended for handwashing purposes. According to U.S. Federal Drug and Administration Food Code 2022, a handwashing sink may not be used for purposes other than handwashing. 12. An observation and concurrent interview with DSM on 12/5/23 at 10:47 a.m., showed two strip bottles, containing test strips for the purpose of testing the strength of the acid based surface sanitizer and the dish-machine chlorine sanitizer solution, were stored in a drawer under the tray line counter. The container with the acid-based sanitizer test strips had a label showing the expiration date of the test strips was September 2023 and the container with the chlorine sanitizer test strips had a label showing the expiration of the test strips was July 1, 2023. The containers of test strips were available for use. DA 1 used the expired acid based test strips to demonstrate how she tested the strength of the acid base surface sanitizer. DSM confirmed the chlorine and acid-based sanitizer test strips were expired and should not be used. During an interview on 12/08/23 at 10:45 a.m. with DSM, DSM stated she was responsible for checking the strips used to test sanitizing solution to ensure they were not expired. DSM also stated expired strips could result in an inaccurate test result of the sanitizing solution. According to U.S. Food and Drug Administration Federal Food Code 2022, the person in charge is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution chemical concentration. In addition, the Food Code annex shows, manufacturers are to provide methods such as test strips to verify the equipment consistently generates a solution on-site at the necessary concentration to achieve sanitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 22 of 28 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 12/08/2023 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to have a policy and procedure to describe how food brought in by family and visitors would be stored safely for the residents. Residents Affected - Many This failure had the potential to negatively impact the residents' dining experience and possibly result in poor food intake for 58 residents who ate food by mouth. Findings: A review of the policy and procedure titled Foods Brought by Family/Visitors with a revision date of October 2017, showed food brought to the facility by visitors and family is permitted. The staff will discard perishable food within the same day or 4-hours from the time food is brought into the facility to prevent risk of foodborne contamination. In an interview with the Director of Staff Development/Infection Preventionist (DSD-IP) on 12/7/23 at 8:25 a.m., DSD-IP stated the facility did not save/store food for residents when food was brought in from the outside by visitors and/or from restaurants because it was not known if the food was stored and/or prepared safely before it was brought into the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 23 of 28 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 12/08/2023 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** 5. During a medication pass observation on 12/5/23, at 1:56 pm, in room [ROOM NUMBER] B, with RN 2, RN 2 did not remove gloves and perform hand hygiene and wear a clean pair of gloves after putting on Resident 16's right hand brace. Then, RN 2 administered oral medications, pulled down each eyelid, and instilled 1 eye drop in each eye of Resident 16. Residents Affected - Some During an interview on 12/5/23, at 3:20 pm, with RN 2, RN2 stated I am sorry. RN 2 acknowledged she should have removed her gloves and performed hand hygiene after handling Resident 16' s hand brace and wear clean gloves before administering the oral medications and eye drops. RN 2 stated it was a risk for cross contamination to Resident. During an interview on 12/8/23, at 9:19 am, with the DSD/IP, the DSD/IP stated staff were expected to follow the facility's infection control protocol, and staff were supposed to be performing hand hygiene and wearing gloves for administration of medications, and if they are doing eye drops, they should be washing their hands. During a review of the facility's P&P titled, Administering medications, dated August 2019, the P&P indicated staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves . etc.,) for the administration of medications, as applicable. Based on observation, interview, and record review, the facility failed to ensure that staff followed proper infection control precautions to prevent spread of infection for five (Resident 16, Resident 55, Resident 21, Resident 60, and Resident 167) of 58 sampled residents when: 1) Resident 167's urinary catheter bag was touching the floor. 2) The nasal cannula for Resident 55 was not changed weekly. 3) The tube feeding for Resident 60 was not dated and labelled. 4) Nursing assistant (NA) did not perform hand hygiene after providing incontinent care to Resident 21. NA did not perform hand hygiene before entering and exiting resident rooms. 5) Registered Nurse 2(RN 2) did not change gloves and perform hand hygiene after handling Resident 16's device, and then gave medications to Resident 16 and applied eye drops. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. During a review of Resident 167's, admission Record, printed on 12/7/23, the admission record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of Bacteremia (Bacteremia is the presence of bacteria in the bloodstream) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should and causes them to gradually lose their ability to function). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 24 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 12/4/23 at 10:28 a.m., with Certified Nursing Assistant (CNA)1, Resident 167's urinary bag and tubing attached to the bottom of the bed, was touching the floor. CNA 1 stated Resident 167's Urinary bag and tubing was touching the floor. CNA 1 stated it should be secured without touching the floor in a privacy bag to prevent infection. During an interview on 12/6/23 at 10:25a.m. with Director of Nursing (DON), DON stated the urinary bags should be secured without touching the floor and covered in privacy bag. DON stated there is risk of infection to the patient. During a review the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, revised in August 2022, the P&P indicated, Infection Control .2. b Be sure the catheter tubing and drainage bag are kept off the floor. 2. During a review of Resident 55's admission Record, printed on 6/14/23, the admission record indicated Resident 55 was originally admitted to the facility in June 2023 with medical diagnosis including Covid-19 (Caused by corona virus often with respiratory symptoms that can feel much like a cold, the flu, or pneumonia. COVID-19 may attack more than your lungs and respiratory system). During a review of Resident 55's, Order Summary, 12/4/23, the order summary indicated, Resident 55 had order for Intermittent oxygen via Nasal canula (a device that delivers extra oxygen through a tube and into your nose.) @1-3 liters (L). Order summary also indicated to change nasal cannula night shift every Sunday. During a concurrent observation and interview on 12/4/23 at 2:45 p.m. with LVN 2, Resident 55's nasal cannula was observed. LVN 1 stated the tubing is dated 11/19/23 at 6 am. LVN 2 stated the nasal cannula should be changed every week. LVN 2 stated if the tubing's are not changed the tubing can get contaminated and can cause lung infections like pneumonia. During an interview on 12/6/23 at 10:20 a.m. with DON, the DON stated their policy is to change the nasal cannula every Sunday night shift and it should be dated and labelled. DON stated it is important due to increased risk of infection and general hygiene issues. During a review the facility's, P&P, titled, Departmental (Respiratory Therapy) - Prevention of Infection ., the policy indicated Infection control considerations related to oxygen Administration .7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 3. During a review of Resident 60's, admission Record, printed on 12/7/23, the admission Record indicated Resident 60 was originally admitted to the facility on [DATE] with medical diagnosis including Dyskinesia of Esophagus (disorders affecting the motor function of the esophagus [the esophagus is the hollow, muscular tube that carries food and liquids from the throat to the stomach]). During a concurrent observation and interview on 12/4/23 at 2:35 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 60's tube feeding in Kangaroo bag (a kind of tube feeding bag) was observed. LVN 1 stated the tube feeding does not have any date or label on it and cannot identify when the feeding was started and/or what type of feeding Resident 60 is receiving. LVN 1 stated it is important to date and label the tube feeding. During a review of Resident 60's, Order Summary, 12/4/23, the Order Summary indicated Resident 60 was receiving tube feeding (a medical device used to provide nutrition to people who cannot obtain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 25 of 28 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 12/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nutrition by mouth, are unable to swallow safely, or need nutritional supplementation): Isosource 1.5.@60ml/hr. with 300 ml water flushes every 4 hours. During an interview on 12/6/23 at 10:18 a.m., with Director of Nursing (DON), the DON stated it is important that Nurses label and date the tube feeding formula to ensure it is the right patient and the right formula. During a review of the facility's P&P titled, Enteral Feedings- Safety Precautions, revised in November 2018, the P&P indicated, General Guidelines. Preventing errors in administration .2. On the formula label document initials, date, and time the formula was hung, and initial that the label was checked against the order. 4. During an observation on 12/7/23 at 2:23 p.m., the Nursing Assistant (NA) came out of Resident room and without performing hand hygiene entered Resident 21's room. NA wore gloves and provided incontinent care to Resident 21. After completion of care, NA removed gloves and did not perform hand hygiene. NA then took the trash bag and disposed the trash bag in the trash bin outside the room. NA then grabbed the dirty linen bin and parked it outside room [ROOM NUMBER]. NA without performing hand hygiene entered room [ROOM NUMBER]. During an interview on 12/7/23 at 2:33 p.m. with NA, NA stated she cleaned the bed for Resident 21 and changed Residents diaper. NA stated after removing gloves they should wash hands, but she forgot to do it. NA stated it is important to prevent patients from getting infections. During an interview on 12/7/23 at 3:30 p.m. with Director of Staff Development/Infection Preventionist (DSD/IP), DSD/IP stated staff should perform hand hygiene before entering residents' room and when exiting rooms. DSD/IP also stated staff should perform hand Hygiene after removing gloves. DSD/IP stated it is important to protect themselves and residents from getting infections. During a review the facility's P&P titled, Handwashing/Hand Hygiene, revised in August 2019, the P&P indicated, Policy interpretation and Implementation .2. All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol: . b. before and after direct contact with residents: .m. after removing gloves: . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 26 of 28 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 12/08/2023 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 - Minimal harm or potential for actual 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 12/4/23 through 12/8/23, there were three residents in Rooms 22, 24, 27, 31, 33, and 35 and 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 12/4/23 to 12/8/23, 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 interfere with resident's 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 12/05/23, at 3:40 p.m., with Resident 6, Resident 6 stated, he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 27 of 28 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 12/08/2023 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 his room. Resident 6 stated, he liked the room. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/05/23, at 3:45 p.m., Resident 22 stated, he is comfortable in his room and had room for his personal belongings. Residents Affected - Some There were no negative consequences resulted from decreased space. No safety concerns for residents in the 12 rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 28 of 28