Health inspection·July 18, 2024

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview on 7/22/24 at 11:28 a.m. with Social Services Director (SSD), SSD stated Social Services Assistant (SSA) took over Resident 2's case some time in May 2024. SSD stated Resident 2's fractured tooth was part of the partial lower dentures. During a review of Resident 2's Care Conference Summary, dated 5/20/24, written and signed by SSA, the Care Conference Summary indicated The resident wears upper and lower dentures, and one tooth has chipped. During a telephone interview on 7/23/24 at 11:43 a.m. with SSA, SSA stated a referral was sent to the dentist on 6/6/24, 16 days after SSA knew of the issue. SSA stated Resident 2 did not have any problems with eating and was able to chew as normal. SSA stated there was no documentation of the extenuating circumstances for the delay in sending the referral. SSA stated she was not aware that referrals for damaged or lost dentures should be made within three days. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility in October 2023 with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (otherwise known as stroke, loss of oxygen supply to the brain leading to damage of brain tissues) and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 3's MRR, dated 7/17/24, the MRR indicated a physician's order, dated 10/19/23, for Resident 3 for Dental consult with treatment and follow-up as indicated. During an interview on 7/16/24 at 1:02 p.m. with Resident 3, Resident 3 stated being admitted in October 2023 to the facility, and some time later Resident 3's full dentures got lost. Resident 3 stated it took a long time for the dentist to come and start the process of replacing dentures. Resident 3 also stated feeling depressed and frustrated by the very slow process. During a review of Resident 3's MDS, dated 4/26/24, Resident 3's BIMS score was 15, indicating intact cognitive response. During a review of Resident 3's Dental Notes, dated 12/12/23, the Dental Notes indicated Resident 3 stated the facility Lost my dentures. The Dental Notes indicated Resident 3 did not have any natural teeth both upper and lower. During a review of Resident 3's Dental Notes, dated 7/9/24, the Dental Notes indicated a full set of dentures with case was ready but was not fitted because of COVID. During an interview on 7/18/24 at 10:02 a.m. with SSA, SSA stated the process of replacing Resident 3's dentures started on 2/6/24 when the dentist came to take dental impressions. SSA stated between then and 7/9/24, the delay was because of the dentist not coming to the facility for timely follow-up. During a telephone interview on 7/23/24 at 1:14 p.m. with SSA, SSA stated Resident 3's new dentures have not been delivered (seven months after report of loss). During a review of the facility's policy and procedure (P&P) titled Dental Services, last revised December 2016, the P&P indicated routine and emergency dental services are provided to the residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 2 of 3 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 07/18/2024 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 0791 Level of Harm - Minimal harm or potential for actual harm the resident's personal dentist, to a community dentist or to other health care organizations that provide dental services. The P&P also indicated if dentures are damaged or lost, residents will be referred for dental services within three days. If the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting dental services, and the reason for the delay. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055292 If continuation sheet Page 3 of 3