Health inspection·June 5, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. 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 enough space was provided for a resident council meeting. Residents Affected - Some This failure had the potential to result in lack of residents participation in group meeting and opportunity to discuss problems or concerns with others. Findings: During a resident council meeting on 6/3/25, at 1:34 p.m., in an empty resident room, six residents seated in wheelchairs were in attendance. Resident 6 stated resident council meetings took place sometimes in Resident 6's room or in empty resident rooms. Resident 6 stated facility did not provide enough space and that empty residents' room did not fit residents willing to participate in group meeting. Resident 6 stated she was not comfortable accommodating resident council meeting in her room. During a review of Resident 6's Minimum Data Set (MDS), (Resident Assessment and care guide tool), dated 4/18/25, MDS indicated Resident 6's BIMS score was 15 meaning intact cognition. MDS indicated Resident 6 had clear speech, able to express ideas and wants. MDS indicated Resident 6 was admitted to the facility on [DATE]. During an interview on 6/3/25, at 2:20 p.m., with Activity Director (AD), AD stated residents used empty rooms for council meetings and space was limited. AD stated there was need for more space because more residents willing to participate were not able to attend. AD stated sometimes instead of residents' group meetings AD did one on one meetings with residents in their rooms to review issues and concerns. AD stated more residents would like to attend but there was no space. During an interview on 6/03/25, at 2:23 p.m., with Administrator (Admin), Admin stated there was no specific room assigned for resident council meetings. Admin stated resident group meetings took place in empty resident rooms. Admin stated facility would provide a new location for resident council meetings. During a review of the facility's policy and procedure (P&P) titled, Resident Council, revised February 2021, the P&P indicated,The resident council group is provided with space, privacy and support to conduct meetings. Page 1 of 11 555364 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for four out of 15 final sampled residents (Residents 7, 10, 20 and 21). This had potential for the facility to provide treatment and services against the residents' wishes. Findings: 1. During a review of Resident 7's admission Record, dated 6/4/25, indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses that included chronic pulmonary embolism (a lung disease that can cause heart failure). During a review of Resident 7's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/28/25 under Section C, indicated a Brief Interview for Mental Status (BIMS-an assessment tool to used to help evaluate cognition in the elderly) score of 14, meaning Resident 7 was cognitively intact . During a review of Resident 7's Physician Orders for Life-Sustaining Treatment (POLST-a form that gives instructions for the resident's care in life-threatening medical situations), dated 10/1/22, under information and signatures, the POLST indicated the resident did not have an advanced directive. Further review of Resident 7's medical record failed to show a copy of an advanced directive. 2. During a review of Resident 10's admission Record, dated 6/4/25, indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss and impaired decision-making capacity). Review of Resident 10's MDS, dated [DATE], under Section C, indicated Resident 10's short and long-term memory was impaired, and had severely impaired decision-making capacity. During a review of Resident 10's POLST form, dated 3/6/19, under information and signatures, the POLST showed no information on the presence of an advanced directive. 3. During a review of Resident 20's admission Record, dated 6/4/25, indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (brain disorder). Review of Resident 20's MDS dated [DATE] under Section C, indicated a BIMS score of 0, meaning Resident 20 had severe cognitive impairment. Review of Resident 20's medical records showed a POLST dated 12/8/20, under information and signatures, indicated the resident did not have an advanced directive. 4. During a review of Resident 21's admission Record, dated 6/4/25, indicated Resident 21 was 555364 Page 2 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0578 admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 21's MDS dated [DATE] under Section C, indicated a BIMS score of 13, meaning Resident 21 was cognitively intact. Residents Affected - Some Review of Resident 21's medical records showed a POLST dated 11/26/21, under information and signatures, indicated the resident did not have an advanced directive. During a concurrent interview and record review on 6/3/25, at 9:08 a.m., with the Social Service Director (SSD), SSD reviewed Residents 7, 10, 20 and 21's medical records and stated there was no documentation that advance directives were discussed and followed up with the residents and their responsible parties. During an interview on 6/3/25, at 3:00 p.m., with the Director of Nursing (DON), the DON stated that the facility residents' advance directives were supposed to be followed up by the Social Services Director (SSD). During a review of the facility's policy and procedure (P&P) titled, Advanced Directives, Revised October 2009, indicated, . Advanced directives will be respected in accordance with state law and facility policy .1. Prior to or upon admission of a resident to our facility, the Social Services Director or Designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives .3. Prior to or upon admission of a resident, the Social Services Director or Designee will inquire of the resident and/or his/her family members about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record . 555364 Page 3 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 two of two sampled residents' (Resident 3 and 31) Preadmission Screening and Resident Review (PASRR) were screened and referred to the appropriate state mental authority for Level II evaluation and determination. Residents Affected - Few (PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). Resident 3 and 31 with diagnosis of schizophrenia were not referred for Level II PASRR evaluation and determination. This failure placed Resident 3 and 31 at risk for inappropriate placement in the facility and prevent Resident 3 and 31 from receiving appropriate required mental health services. Findings: During a review of Resident 3's admission Record (AR), dated June 4, 2025, AR indicated Resident 3 was originally admitted to the facility on [DATE] with diagnosis that included schizophrenia (a chronic mental illness that affects how a person thinks, feels and behaves, often making it difficult to distinguish between reality and imagination). During a concurrent interview and record review on 6/4/25, at 9:05 a.m., with Director of Nursing(DON) and MDSC coordinator (MDSC 1), Resident 3's PASRR Level I screening result dated 3/24/25 was reviewed. DON stated she was not aware of the need to refer Resident 3 for Level II evaluation. During a review of Resident 31's admission Record (AR), dated June 4, 2025, AR indicated Resident 31 was originally admitted to the facility on [DATE] with diagnosis that included schizophrenia. During a concurrent interview and record review on 6/4/25, at 9:05 a.m., with Director of Nursing(DON) and MDSC coordinator (MDSC 1), Resident 31's PASRR Level I screening result dated 4/14/21 was reviewed. DON stated she was not aware of the need to refer Resident 31 for PASRR Level II evaluation. 555364 Page 4 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 14 received adequate bed mobility supervision and assistance to prevent the resident from falling to the floor. This deficient practice resulted in resident 14 falling on the floor and sustaining a left femur fracture (left femur fracture is a break in the left thighbone. It often causes severe pain and swelling). Findings: During a review of Resident 14's Facesheet (information containing contact details, brief medical history at-a-glance) printed 6/4/25, the facesheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, hemiplegia and hemiparesis (morbid obesity means having a body weight that is much higher than what is considered healthy; hemiplegia is paralysis that affects only one side of the body and hemiparesis is a condition characterized by weakness on one side of the body). During a review of Resident 14's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/10/25, indicated Resident 14 had a brief interview for mental status or BIMS score of 10 (BIMS score of 8 to 12 indicates moderate cognitive impairment). The MDS also indicated Resident 14 needed substantial to maximal assistance when rolling from lying on back to left and right side which meant when helping the resident to turn from side to side, the helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. During a review of Resident 14's Activities of Daily Living (ADL) care plan indicated Resident 14 required extensive assistance by two staff to turn and reposition in bed every two hours and as necessary. During a review of facility's Interdisciplinary Team's notes (IDT, a group of individuals representing different departments of the facility), dated 3/21/25, indicated on 3/15/25 at 6:56 a.m., Resident 14 was rolled out of bed by Certified Nursing Assistant (CNA) 1 to the floor while providing care. The IDT notes also indicated Resident 14 was screaming in pain and was transferred to the hospital by 911. The IDT notes further indicated a plan of action of maintaining two persons assist during ADL care and to provide more teaching to CNA 1. During a review of Resident 14's Hospitalist (physician specialist in hospital care) History and Physical (H & P) dated 3/20/25, indicated Resident 14 sustained left femur fracture. During an interview on 6/4/25, at 10:09 a.m., with Resident 14, Resident 14 complained of left hip pain and stated she fell from her bed but could not remember when the incident happened. During a telephone interview on 6/4/25, at 10:11 a.m., with CNA 1, CNA 1 acknowledged she needed another person to help her turn Resident 14 from side to side, but she did not ask for assistance. CNA 1 stated Resident 14's bed was in a high position when she fell from the bed. During an interview on 6/4/25, at 11:10 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 14 555364 Page 5 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few required two to three persons to assist when being turned and repositioned due to the resident's morbid obesity. During an interview on 6/4/25, at 2:05 p.m., with Director of Rehabilitation (DOR), DOR stated Resident 14's fall was avoidable and could have been prevented if the CNA asked for help. DOR stated the resident needed two persons assistance all the time when being turned and repositioned in bed. 555364 Page 6 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, and record review, the facility failed to ensure Consultant Pharmacist (CP) provided consultation on all aspects of the pharmacy services in the facility when : Residents Affected - Some 1. Loose pills were observed in med cart 2. Formula bottles were stored in the cabinet underneath hand washing sink. 3. CP did not assist with disposition of discontinued controlled drugs in sufficient detail to enable an accurate reconciliation. These failures had the potential to result in medication error, contamination of tube feeding formula and possible diversion of controlled drugs. Findings: During a concurrent observation and interview on 6/3/25, at 12:05 p.m., with Registered Nurse (RN) 1 in the medication storage room, thirteen bottles of tube feeding formula were stored in a cabinet underneath the hand wash sink. RN 1 stated she did not know about the storage underneath the hand wash sink. During a concurrent observation and interview on 6/3/25, at 12:18 p.m., with RN 1, the medication cart was reviewed and loose pills were found in the cart behind medication cards. RN 1 stated she did not know about the loose pills. During a concurrent observation and interview on 6/3/25, at 12:31 p.m., with Director of Nursing (DON), in the medication room, thirteen bottles of tube feeding formula were stored under the hand wash sink. DON stated she would remove the stored formula to another location. DON stated facility had a container for loose pills and expected licensed nurses to dispose of medications properly. During further observation and concurrent interview on 6/3/25, at 12: 31 p.m., in the medication room, a cabinet was full of discontinued narcotic medications . DON stated CP last destroyed discontinued narcotics on 11/5/24. DON stated CP remotely reviewed residents medication records. DON stated CP had not visited the facility to assist with the destruction of the discontinued medications. During an interview on 6/4/25, at 8:10 a.m., with Administrator (Admin), Admin stated CP had been inconsistent with visit to facility and did medication review remotely . Admin stated CP had continued to be remote since COVID-19 period. Admin stated he had made several attempts to communicate with CP with no response. Admin stated CP had not attended quarterly Quality Assurance Committee (QA) meetings, with the last documented CP attendance of QA committee meeting in 2022. During an interview on 6/5/25, at 11:23 a.m., with CP's Director of Clinical Operation (DCO), DCO stated he was not aware that assigned CP was not physically present at the facility. DCO stated that not physically visiting and attending QA meetings was not an operational policy; the expectation was for CP to be present in the facility and physically visit . DCO stated the CP should still go into the facility for drug destruction and QA attendance. DCO stated it was the Pharmacy policy to be at the facility physically. 555364 Page 7 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

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, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: Residents Affected - Some 1. Two expired containers of sour cream were stored in the kitchen refrigerator. 2. One opened plastic bag of soggy salad was stored in the kitchen refrigerator. 3. Storage used for kitchen utensils was not clean. These failures put the facility at increased risk for food contamination and food borne illness for 33 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview during the initial kitchen tour on 6/2/25, at 9:14 a.m., with the Dietary Supervisor (DS), two expired containers of sour cream were in the kitchen refrigerator. One of the two containers was opened and was almost empty. DS stated the expired sour cream should have been disposed and further stated that the risk for the residents consuming the expired sour cream was stomach upset. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage of Cold Foods, dated 2023, indicated, All the perishable food items purchased by the department of food and dining services will be stored properly. Perishable food will be kept refrigerated or frozen . All open food items will have an open date and use-by-date per manufacturer's guidelines . 2. During a concurrent observation and interview during the initial kitchen tour on 6/2/25, at 9:18 a.m., with the DS, one opened plastic bag of soggy salad was in the refrigerator. DS stated the bag of salad should have been thrown away. DS stated risk for the residents eating the soggy salad was stomach upset. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage of Cold Foods, dated 2023, indicated, All the perishable food items purchased by the department of food and dining services will be stored properly. Perishable food will be kept refrigerated or frozen . All open food items will have an open date and use-by-date per manufacturer's guidelines . 3. During a concurrent observation and interview during the initial kitchen tour on 6/2/25, at 9:25 a.m., with the DS, the utensil holder which stored kitchen utensils used for cooking had brownish stains all over and scattered brownish particles. DS acknowledged that the utensil holder was dirty and that the risk of storing the kitchen utensils in the holder was cross contamination. During a review of the facility's P&P titled, Sanitizing Equipment, Food and Utility Carts, dated 2023, indicated, .All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use . According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease 555364 Page 8 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0812 deposits and other soil accumulations, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555364 Page 9 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow one of 15 sampled resident (Resident 139) to store food brought by family member in the facility's refrigerator. Residents Affected - Some This failure resulted in Resident 139 not being able to store food brought from home to the facility. Findings: During a resident council meeting (resident council meeting is a group meeting of residents living in the facility that meets once a month to discuss concerns, develop suggestions on improving services, or resolve differences) on 6/3/25, at 1:34 p.m., with six residents, Resident 139 stated when her family brought her food, she ate the food immediately and shared it with her care giver because facility had no refrigerator to store food for the residents. Resident 139 stated the facility should have small refrigerator to keep and store food for residents. Resident 139 also stated the facility did not offer a refrigerator. During a review of Resident 139's admission Record (AR), dated 6/4/25, indicated, Resident 139 was admitted to the facility on [DATE]. A review of Resident 139's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/28/25, the MDS indicated Resident 139 had a Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score of 15 out of 15, meaning intact cognition. During an interview on 6/03/25, 12:19 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, the facility used to have a refrigerator for the residents' food brought from home and stated she could not remember when it broke, but it was not replaced. The ADON further stated when the family members brought food for the residents, the facility asked the residents' families just to bring enough food that the residents could eat, and the facility asked the residents' families to bring home the food that the residents could not consume. During an interview on 6/3/25, at 2:54 p.m., with the Director of Nursing (DON), the DON stated, the facility did not have a refrigerator for food brought from home. During a review of the facility's policy and procedure (P&P) titled, Food brought by Family/Visitors, Revised March 2022, the P&P indicated, . Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility prepared food. a. Non-perishable foods are stored in a resealable container with tight fitting lids . b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the residents' name, the item and the use by date . 555364 Page 10 of 11 555364 06/05/2025 Shields Nursing Center 3230 Carlson Boulevard El Cerrito, CA 94530

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to follow its hospice policy and procedure to collaborate, develop and implement a coordinated plan of care (POC) with hospice representatives for one sampled resident (Resident 18) admitted into hospice program, when Resident 18's hospice POC did not reflect the participation of hospice representatives, Resident 18 and Resident 18's representatives. {POC means a written plan of care established, maintained, reviewed, and modified as necessary, for an individual that reflects the participation of hospice, facility, the patient and patient's family, as appropriate and complies applicable to federal and state laws and regulations}. {Hospice- a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease}. This failure had the potential to result in Resident 18 not receiving necessary care and services. Findings: During a review of Resident 18's admission Record (AR), dated 6/4/25, the AR indicated, Resident 18 was admitted to facility on 5/7/25 with principal diagnosis of disorder of brain. During a review of Resident 18's Admission-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/13/25, indicated Resident 18 was on hospice. During a review of Resident 18's hospice service notes, dated 5/7/25, indicated start hospice order. During an interview on 6/4/25, at 9:15 a.m., with Social Services (SSD), SSD stated she was designated to coordinate hospice care provided to Resident 18. SSD stated she had not scheduled a POC conference for Resident 18 with hospice provider. SSD stated facility had not collaborated with hospice representative . SSD stated she was aware of need to schedule a POC conference with hospice provider, but the care conference had not been scheduled. During a concurrent interview and record review on 6/4/25, at 9:20 a.m., with Director of Nursing (DON), Resident 18's care plan reports, hospice agreement and physician orders were reviewed. DON stated social services was designated to coordinate the care plan conference with hospice agency and Resident 18's family members. DON stated Resident 18 and hospice representative had not been invited to participate in development of Resident 18's hospice care plan in collaboration with hospice agency. DON stated facility had not met to collaborate with hospice representatives on Resident 18 POC. DON stated it was an oversight. During a review of facility's policy and procedure (P&P) titled, Hospice Program, revised July 2017, the P&P indicated, Our facility had designated (name) to coordinate care provided to the resident by our facility staff and hospice staff. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services). 555364 Page 11 of 11