Health inspection·April 4, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to provide Resident 1 a notice of proposed discharge within the timeframe of at least 30 days prior to the actual discharge date and failed to send a copy to the Office of the State Long-Term Care Ombudsman as required. This failure had the potential to result in the lack of added protection to Resident 1 from being inappropriately discharged , without access to an advocate who can inform them of options and rights. Findings: During a review of Resident 1's admission Record, dated 4/4/24, the admission Record indicated Resident 1 was admitted to the facility in November 2023 with diagnoses that included cerebral palsy (a group of conditions that affect muscle movement and posture. Symptoms include exaggerated reflexes, floppy or rigid movements and involuntary motions), dysphagia (difficulty swallowing), repeated falls, rhabdomyolysis (life-threatening condition, as a result of muscle injury, muscles break down and releases protein into the blood, this protein damages the kidney), syncope and collapse (fainting, sudden loss of consciousness), and dorsalgia (mild to disabling pain occurring on the spine or back). The admission Record indicated Resident 1 was self-responsible and Caregiver (CG) was Emergency Contact #1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 11/28/23, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information.) score of three (A BIMS score of three is an indication of severe cognitive impairment). During a review of Resident 1's Order Summary Report, dated 11/23/24, the Order Summary Report indicated an order for Resident 1 to be discharged home on 1/23/24. During a review of Resident 1's Notice of Proposed Transfer/Discharge with notification date 1/18/24, the Notice of Proposed Transfer/Discharge indicated Resident 1 was being discharged because Resident 1's health has improved sufficiently that Resident 1 no longer needed the services provided by the facility. The Notice of Proposed Transfer/Discharge was signed by CG on 1/23/24, and indicated, If you intend to file an appeal, it is suggested you do so within 10 calendar days of being notified .the decision regarding an appeal will normally be made within thirty (30) working days from the date you were formally notified . The notice also indicated it was required that a copy of it be faxed to the State Long Term Care Ombudsman office and proof the document was faxed will be filed in Page 1 of 5 555364 555364 04/04/2024 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0623 Resident 1's medical record. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/4/24 at 12:01 p.m. with Physical Therapist (PT), PT stated prior to admission to the facility, Resident 1 was able to walk, but had been falling frequently at home, hence the hospitalization and eventually admission to the facility. PT stated Resident 1's ability to perform ADLs (activities of daily living like turning and repositioning in bed, transfer from bed to chair and back, toilet use, personal hygiene and eating) fluctuated and still needed 24-hour care at the time of discharge. Residents Affected - Few During a telephone interview on 4/9/24 at 10:42 a.m. with Administrator (Adm), Adm stated he did not know if Social Services Director sent a copy of the discharge notice to the Ombudsman office. Adm stated there was no facility policy and procedure that addressed discharge notices. As of 4/9/24 at 4:13 p.m., Adm was not able to provide a proof that the Notice of Proposed Transfer/Discharge issued to Resident 1 on 1/23/24 was sent to the State Long Term Care Ombudsman Office. 555364 Page 2 of 5 555364 04/04/2024 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one of two (Resident 1) sampled residents who were discharged from the facility, the facility failed to implement effective discharge planning when Resident 1, who required 24-hour care, was discharged without consideration for Resident 1's discharge needs such as caregiver support availability and mechanically altered diet (foods that can be safely and successfully swallowed). Residents Affected - Few This failure resulted in Resident 1's re-admission to the hospital. Findings: During a review of Resident 1's admission Record, dated 4/4/24, the admission Record indicated Resident 1 was admitted to the facility in November 2023 with diagnoses that included cerebral palsy (a group of conditions that affect muscle movement and posture. Symptoms include exaggerated reflexes, floppy or rigid movements and involuntary motions), dysphagia (difficulty swallowing), repeated falls, rhabdomyolysis (life-threatening condition, as a result of muscle injury, muscles break down and releases protein into the blood, this protein damages the kidney), syncope and collapse (fainting, sudden loss of consciousness), and dorsalgia (mild to disabling pain occurring on the spine or back). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 11/28/23, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information.) score of three (A BIMS score of three is an indication of severe cognitive impairment). During an interview and concurrent review on 4/4/24 at 10:56 a.m. with Social Services Director (SSD), Resident 1's Care Conference Summary, dated 11/22/23, was reviewed. SSD stated during the Care Conference for initial discharge planning, Resident 1's family agreed to take Resident 1 home only when Resident 1 was able to use the bathroom independently, without needing physical help from another person. The Care Conference Summary indicated Resident and caregiver both verbalized that upon discharge from SNF [skilled nursing facility], resident will return home. [Resident 1] needs to work hard with PT [physical therapy] and OT [occupational therapy] and be able to go back to his baseline. SSD will provide resources to fit resident needs. During a review of Resident 1's Inpatient Medicine Discharge Summary (from prior hospitalization), dated 11/15/23, the Inpatient Medicine Discharge Summary indicated Resident 1 had five unwitnessed falls at home prior to admission to the hospital. Resident 1 was discharged to the facility for physical therapy as Resident 1 independently performed his activities of daily living like turning and repositioning in bed, transfer from bed to chair and back, toilet use, personal hygiene and eating (ADLs) with intermittent help from Caregiver (CG) a few hours a day. During a review of Resident 1's Care Conference Summary, dated 1/18/24, the Care Conference Summary indicated Resident 1 had reached functional goals and will be discharged home with family, caregiver, and home health care services. During a review of Resident 1's Order Summary Report, dated 11/23/24, the Order Summary Report indicated an order, dated 11/28/23, for speech therapy to evaluate and treat Resident 1's dysphagia. The Order Summary Report also indicated an order for Resident 1 to be discharged home on 1/23/24. 555364 Page 3 of 5 555364 04/04/2024 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Discharge Plan of Care, dated 1/22/24, the Discharge Plan of Care indicated Resident 1 needed 24-hour care for minimal to moderate assistance with transfers and walking with front wheel walker and for Resident 1's diet to be regular puree, nectar thick liquid. During an interview and concurrent review of Resident 1's Discharge Plan of Care, dated 1/22/24, on 4/4/24 at 11:38 a.m. with Director of Nursing (DON), DON stated not being aware of Resident 1's need for 24-hour care as indicated in the Discharge Plan of Care. DON stated if she had been aware, it would have changed Resident 1's discharge plan to stay at the facility for long-term care. DON stated Resident 1 had coverage for long term stay. DON also stated the Discharge Plan of Care was the last paperwork to be completed by a representative of each department and issued to Resident 1 on the day of actual discharge and may not have been reviewed by the entire team. During an interview on 4/4/24 at 12:01 p.m. with Physical Therapist (PT), PT stated prior to admission to the facility, Resident 1 was able to walk, but had been falling frequently at home, hence the hospitalization and eventually admission to the facility. PT stated Resident 1's ability to perform ADLs fluctuated and still needed 24-hour care at the time of discharge. PT stated Resident 1 had a caregiver who did not show up for caregiver training with therapy. During a review of Resident 1's Physical Therapy Discharge Summary, dated 1/13/24, the Physical Therapy Discharge Summary indicated Resident 1 was able to turn, reposition in bed, and transfer in and out of bed with minimal assistance and able to walk on level surfaces with moderate assistance. The summary also indicated discharge reason as discharged per Physician or Case Manager. During a second interview and concurrent review of Resident 1's clinical records on 4/4/24 at 12:51 p.m. with SSD, Resident 1's Discharge Plan of Care, dated 1/22/24, was reviewed. SSD stated she thought Resident 1 only needed some assistance with ADLs and not needing 24-hour care. During a telephone interview on 4/8/24 at 1:12 p.m. with CG, CG stated being told Resident 1's insurance would not cover for long term-stay at the facility, so facility needed to discharge Resident 1. CG stated telling the facility staff of being unable to care for Resident 1 but was told Resident 1 could walk and go to the bathroom independently and not needing much help which turned out to be untrue. CD stated the night Resident 1 came home, Resident 1 fell, and CG had to go to Resident 1's home because Resident 1's sister was also bedridden and could not pick up Resident 1 off the floor. CG stated Resident 1 had four more falls over two days after that night. CG stated not being able to provide 24-hour care for Resident 1 as CG only went to Resident 1's home an hour a day, five days a week. CG stated, five days after being discharged from the facility, Resident 1 was sent to the hospital for severe pain and for repeated falls. CG also stated one had to prepare pureed food and thickened soup for Resident 1 to eat at night when CG was not at the home. During a review of the Attending Physician's Progress Notes, dated 11/22/23, the Progress Notes indicated for Resident 1's dysphagia, Continue ST swallow evaluation, Unclear why [Resident 1] is having this trouble. During an interview on 4/4/24 at 12:40 p.m. with SSD, SSD stated there was no ST evaluation and treatment done on Resident 1. During a telephone interview on 4/9/24 at 10:42 a.m. with Administrator (Adm), Adm stated appropriate discharge for a resident who needed 24-hour care should be to an assisted living facility if the resident was financially able and willing to pay, to a care home, or to another skilled nursing 555364 Page 4 of 5 555364 04/04/2024 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0660 facility of choice. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled Discharge Summary and Plan, last revised December 2016, and Resident 1's Discharge Plan of Care, dated 1/22/24, the P&P indicated a post-discharge plan will be developed by the Interdisciplinary Team With the assistance of the resident and his or her family and will include . c. A description of the resident's stated discharge goals; d. The degree of caregiver support person/availability, capacity, and capability to perform required care; . f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. The Resident 1's Discharge Plan of Care did not indicate any of this information. Residents Affected - Few 555364 Page 5 of 5