Inspection·December 11, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of three sampled residents (Resident 1) when Treatment Nurse 1 (TN 1) did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove changes during the wound dressing change. This failure had the potential to result in infection and spread of infection. Residents Affected - Few Findings: A review of Resident 1s admission Record, printed 12/11/24, indicated resident was readmitted to the facility on [DATE] with diagnosis of diabetes mellitus (high blood sugar). A review of Resident 1's Physician Order, with a revision date of 12/5/24, indicated a treatment order for resident's sacral region (the triangular shaped bone at the base of the spine that connects the spine to the pelvis) Stage III pressure ulcer (a full thickness tissue loss but do not reach muscle, tendon, or bone). The treatment order indicated, Wound care: Cleanse with normal saline (NS), gently pat dry, apply Santyl (a topical enzyme [proteins that help with wound healing] medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin), cover with Mepilex (a soft and highly conformable antimicrobial foam dressing) until healed one time a day . During a concurrent observation and interview on 12/11/24, at 1:20 p.m., TN 1 prepared for Resident 1's wound dressing change. Resident's old wound dressing has been removed during incontinent care just before the wound care began. TN 1 donned a clean pair of gloves, cleansed the wound site with NS, removed soiled gloves, then donned a new pair to apply Santyl to the wound, without performing hand hygiene. As TN 1 continued with Resident 1's wound care, TN 1 covered the wound site with Mepilex dressing, removed her soiled gloves, then donned a new pair again without performing hand hygiene. Upon interview, TN 1 stated hand hygiene should be performed when moving from wound cleaning (a dirty procedure) to application of a new dressing (a clean procedure) to prevent contamination. During an interview on 12/11/24, at 2 p.m., with the Director of Nursing (DON), DON stated changing gloves without performing hand washing or hand hygiene increases the risk of infection. DON stated staff should change gloves and perform hand hygiene in between clean and dirty procedures to prevent spread of infection. A review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised date August 2019, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055292 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 12/11/2024 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)