Health inspection·November 17, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to provide necessary services to maintain good grooming to one sampled resident (Resident 25). Residents Affected - Few This deficient practice had the potential for Resident 25 to accidentally scratch her skin with long and jagged fingernails, have skin problems around the nail bed, infection, and low self-esteem. Findings: During a concurrent observation and interview on 11/13/23 at 9:25 a.m., Resident 25 was observed with long, jagged fingernails. There were thick dark brown substances underneath her nails. Resident 25 apologized for having long and dirty fingernails. Resident 25 stated she preferred short, well-trimmed fingernails, however, she did not have a nail clipper. During an observation of Resident 25 and concurrent interview with Certified Nursing Assistant (CNA)1 and Registered Nurse (RN)1 on 11/14/23 at 12:10 p.m., CNA 1 and RN 1both confirmed the nails of Resident 25 were long and dirty. CNA 1 stated they were supposed to trim the residents' fingernails when they are long and clean underneath fingernails each time they washed their hands. During a review of Resident 25's Admissions Records, the records indicated she was admitted to the facility in April 2022 with diagnoses that included: peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), obsessive-compulsive disorder (excessive thoughts that lead to repetitive behaviors), and schizophrenia (a disorder which affects a person's ability to think, feel and behave clearly). During a review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/13/23, the MDS indicated moderate cognitive impairment and required moderate assistance with activities of daily living. During a review of the facility's policy and procedure titled: Fingernails/Toenails, Care of, dated February 2018, the policy indicated under General Guidelines: 1. Nail care includes daily cleaning and regular trimming, 2. Proper nail care can aid in the prevention of skin problems around the nail bed, 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Page 1 of 6 555364 555364 11/17/2023 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility administered a crushed tablet of carbamazepine ER (carbamazepine ER is an extended release medication, releasing medication into the body over a 12 hour period, used to treat and relieve nerve pain) 100 milligrams (mg) to one (Resident 136) of eight sampled residents. Residents Affected - Few This failure resulted in Resident 136 not receiving medication as prescribed by the physician and placed Resident 136's health at risk due to risk of an adverse effect on Resident 136's trigeminal neuralgia (a condition that causes nerve pain) and health. Findings: During a review of Resident 136's admission Record (AR), printed 11/14/23, the AR indicated Resident 136 was admitted to the facility in October 2023, and had a diagnosis of trigeminal neuralgia. During a concurrent observation and interview on 11/14/23 at 8:17 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he crushed Resident 136's medications. LVN 1 crushed Resident 136's carbamazepine ER 100 mg tablet and gave it to Resident 136 in applesauce. During a review of Resident 136's Medication Review Report (MRR), dated 11/14/23, the MRR indicated, Carbamazepine ER Oral Tablet Extended Release 12 Hour 100 MG (Carbamazepine) Give 1 tablet by mouth one time a day . During a review of Resident 136's Medication Administration Record (MAR), dated 11/1/23 - 11/30/23, the MAR indicated Resident 136 received one tablet of Carbamazepine ER Oral Tablet Extended Release 12 Hour 100 MG on 11/14/23 at 8:00 a.m. During an interview on 11/14/23 at 10:37 a.m., with Director of Nursing (DON), DON stated, Resident 136's carbamazepine ER should not have been crushed, because it was an extended release medication. DON stated, the extended release medication was meant to be released into the body over time, but when given crushed the medication was released into the body all at one time. DON stated, receiving the crushed medication had the risk of adversely affecting Resident 136's health by adversely affecting his Trigeminal Neuralgia. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated Revised April 2019, the P&P indicated, . 4. Medications are administered in accordance with prescriber orders . During a review of the facility's policy and procedure (P&P) titled, Crushing Medications, dated Revised April 2018, the P&P indicated, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. 555364 Page 2 of 6 555364 11/17/2023 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure insulin (medication used to treat and manage blood sugar) was kept in locked storage. This failure resulted in insulin being left unattended on top of the medication cart accessible to unauthorized individuals. Findings: During an observation on 11/14/23 at 11:30 a.m., at the medication cart located next to the nurse's station, Registered Nurse (RN) 1 placed an unlocked plastic box containing vials of insulin on top of the medication cart. RN 1 walked away from the cart, leaving it unattended, and into Resident 17's room and gave Resident 17 an insulin injection. During an observation on 11/14/23 at 11: 43 a.m., RN 1 returned to the medication cart and obtained the equipment necessary to test Resident 16's blood sugar. The unlocked box containing vials of insulin remained on top of the medication cart while RN 1 left the cart unattended and went into Resident 16's room. During an interview on 11/14/23 at 11:45 a.m., with RN 1, RN 1 stated the box containing the insulin vials should have been locked up inside the medication cart when he left the cart unattended to prevent an unauthorized person from taking the insulin. During an interview on 11/14/23 at 12:10 p.m., with Director of Nursing (DON), DON stated the insulin should have been kept locked in the medication cart and not left unattended on top of the cart. DON stated that unattended insulin vials on top of the medication cart posed a risk that an unauthorized person could take and administer the insulin, which posed a risk of harm to the person's health. During a review of Resident 17's admission Record (AR), printed 11/14/23, the AR indicated, Resident 17 was diagnosed with diabetes mellitus (a chronic disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 17's Medication Record Report (MRR), dated 11/14/23, the MRR indicated, Finger stick blood glucose QAC (before every meal) and QHS (at every bedtime) four times a day. During a review of Resident 16's admission Record (AR), printed 11/14/23, the AR indicated, Resident 16 was diagnosed with diabetes mellitus. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated Revised February 2023, indicated, The facility stores all medications and biologicals in locked compartments . 4. Compartments (including, but not limited to, drawers . carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 555364 Page 3 of 6 555364 11/17/2023 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to follow safe food practices when: Residents Affected - Many 1. Two plastic bags of chicken parts were unlabeled and undated. 2. One plastic bag of sausage links was unlabeled and undated. These failures placed residents at risk for foodborne illnesses. Findings: During an observation on 11/13/23 at 9:30 a.m. in the kitchen, the freezer contained two plastic bags of frozen chicken parts which were undated and had no label identifying the contents and one plastic bag of sausage links which was undated and had no label identifying the contents. During an interview on 11/13/23 at 9:32 a.m. with Dietary Manager (DM), DM stated two plastic bags containing chicken parts and one plastic bag containing sausage links were in the freezer and were undated and had no labels identifying the contents. DM stated the three bags were supposed to be labeled and dated so the food was identified and was not kept too long. During an interview on 11/15/23 at 12:00 PM with Registered Dietician (RD), RD stated all food in the freezer should be labeled and dated. RD stated the bags of chicken parts and sausages should have been labeled identifying the contents and dated. RD stated not being labeled and dated could lead to use of food that was outside of the date when food could be used safely, could lead to the use of spoiled food, and increased risk of foodborne illness. 555364 Page 4 of 6 555364 11/17/2023 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

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 follow infection control procedures when: Residents Affected - Many 1. The facility did not have procedures in place for monitoring and testing the presence of Legionella and other water borne pathogens in their water system. 2. The facility did not properly label, disinfect and store wash basins. 3. A licensed nurse failed to disinfect reusable medical equipment between resident use. Findings: 1. During an interview with the administrator on 11/15/23 at 10:15 a.m. and concurrent review of the facility's water management system, the administrator stated the facility did not have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens (microorganism, bacterium or virus that cause a disease) that was based on nationally accepted standards. The administrator stated the facility was in the process of finding a vendor who would provide Legionella testing to the facility. 2. During multiple observations of resident bathrooms on 11/13/23, 11/14/23, and 11/15/23, there were piles of wash basins laying on the bathroom floor of rooms [ROOM NUMBERS], 4 and 5, and 6 and 7. The wash basins were not labeled with the name of a resident, they were dirty and had soap scum on the rims. During an interview with the infection preventionist (IP) on 11/15/23 at 2:00 p.m., IP stated the wash basins should not be on the floor and should be washed after each use. During an interview with the Director of Nursing (DON) on 11/16/23 at 8:45 a.m., DON stated the wash basins should be labeled with the resident's name, washed, disinfected, and stored in the resident's bedside table. 3. During an observation on 11/14/23 at 11:30 a.m., Registered Nurse (RN) 1 used a glucometer (a handheld instrument that tests the amount of sugar in a drop of a person's blood) to test the amount of glucose (sugar) in Resident 17's blood. During an observation on 11/14/23 at 11:43 a.m., RN 1 used the same glucometer to test Resident 16's blood glucose. RN 1 did not sanitize the glucometer between testing Resident 17's blood and Resident 16's blood. During an interview on 11/14/23 at 11:45 a.m. with RN 1, RN 1 stated the glucometer should have been sanitized between testing Resident 16 and Resident 17 to decrease the risk of the spread of infection. During an interview on 11/14/23 at 12:10 p.m. with DON, DON stated RN 1 should have sanitized the glucometer between testing the blood of Resident 16 and 17 to reduce the risk of the spread of infection. 555364 Page 5 of 6 555364 11/17/2023 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of Resident 17's admission Record (AR), printed 11/14/23, the AR indicated, Resident 17 was diagnosed with diabetes mellitus (a chronic disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 17's Medication Record Report (MRR), dated 11/14/23, the MRR indicated, Finger stick blood glucose QAC (before every meal) and QHS (at bedtime) four times a day. During a review of Resident 16's admission Record (AR), printed 11/14/23, the AR indicated, Resident 16 was diagnosed with diabetes mellitus. During a review of the facility's policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, dated Revised October 2011, the P&P indicated, 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. 555364 Page 6 of 6