Shields Nursing Center

Inspectors wroteBased on interview and record review the facility failed to ensure necessary treatment and care services were provided for one (Resident1) of three sampled residents in accordance with professional standards of practice and care plan when: 1. Facility did not reevaluate Resident 1's routine administered of Acetaminophen (Tylenol) medication twice a day for pain management when Resident 1's pain symptoms had resolved. (Tylenol - medication used to relieve mild to moderate pain and reduce fever). 2. Facility did not carry out diagnostic laboratory tests dated 8/30/24 for Resident 1 as ordered by the physician. 3. Facility did not monitor Resident 1's fluid intake and output record as indicated on care plan. 4. LVN 1 did not notify physician and document failed attempts to obtain STAT UA specimen via straight catheterization for Resident 1. STAT lab order means immediately. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents' medical records was accurately documented and systematically organized when Licensed Vocational Nurse (LVN1) did not document in Resident 1's medical records, the physician order to obtain STAT laboratory test for urinalysis (UA) and straight catheterization to include the date and time the order was received in accordance with accepted professional standards and practices. This failure had the potential to cause inaccurate documentation and confusion of care and treatment provided for Resident 1. During an interview on 9/29/25 at 3:25 p.m. with LVN 1, LVN 1 stated an order for a STAT lab test for UA, blood work and straight catheter to obtain UA specimen were received for Resident 1 a day before Resident 1 was transferred to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for reporting an outbreak of communicable disease (COVID-19) when; Administrator (Admin) did not report to the health department two cases among residents positive for COVID-19. This failure had the potential for spread of COVID-19 virus among residents and place residents at risk for infections. During an interview on 8/13/25 at 11:05 a.m. with Director of Nursing (DON), DON stated facility had two residents that was positive for COVID-19. DON stated these cases happened in July 2025. DON stated Resident 1 was transferred to the hospital for shortness of breath and tested positive for COVID-19. During a review of Resident 1's hospital notes, dated 7/30/25, indicated Resident 1 presents to the emergency department (ED) after an episode of hypoxia and decrease responsiveness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure enough space was provided for a resident council meeting. This failure had the potential to result in lack of residents participation in group meeting and opportunity to discuss problems or concerns with others.

Inspectors wroteBased 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.

Inspectors wroteBased 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 : 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.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 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.

Inspectors wroteBased 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. This failure resulted in Resident 139 not being able to store food brought from home to the facility.

Inspectors wroteBased 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. (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.

Inspectors wroteBased 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).

Inspectors wroteBased 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}. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 ' s representative (RR) received copies of medical records within forty-eight hours from requested date. This failure resulted in RR not receiving requested documents for forty-two days.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the coccyx (tailbone) pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) wound for one (Resident 1) of three sampled residents. This failure had the potential for Resident 1 ' s wound to worsen, delay wound healing, have pain, infection and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS, an assessment tool used to direct resident care) for one of two sampled residents (Resident 1) within the regulatory specified timeframes when the Minimum Data Set Coordinator (MDSC) did not complete the admission assessment within 14 calendar days of Resident 1 ' s admission to the facility. This deficient practice had the potential to result in Resident1 ' s unassessed and unmet care needs.

Inspectors wroteBased 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.

Inspectors wroteBased 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). This failure resulted in Resident 1's re-admission to the hospital.

Inspectors wroteBased on observation and interview, the facility failed to follow safe food practices when: 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures when: 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.

Inspectors wroteBased on observation and interview, the facility failed to provide necessary services to maintain good grooming to one sampled resident (Resident 25). 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Infection Preventionist (IP) was present at the Quality Assurance and Performance Improvement Quality Assessment and Assurance (QAPI/QAA) meetings for 3 monthly meetings. This failure had the potential to result in failed recognition of infection-associated concerns (infections acquired in the facility, infection outbreaks, inappropriate use of antibiotics) and lack of development for infection control performance improvement projects with resultant increased infection and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Have measures to in place to prevent the growth of Legionella and other opportunistic and water-borne pathogens in the facility water systems. 2. Ensure staff performed hand hygiene before putting on gloves and between glove changes during a wound care dressing change for one of one residents (Resident 20). 3. Maintain sanitary and hygienic conditions for two of seven residents (Resident 20, Resident 26) when Resident 20 and 26 had unlabeled nasal cannula oxygen tubing (a lightweight tube worn under the nose, with two prongs inserted into the nostrils to deliver supplemental air and/or oxygen), and no documented changes of the nasal cannula oxygen tubing. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed for three months to ensure they had at least a part-time designated infection preventionist (IP, a designated staff member to ensure healthcare workers and residents are doing all the things they should to prevent infections and meets specific qualifications through education, training, experience, or certification) to be responsible for the infection prevention and control program (IPCP, program established to provide evidence-based practices to prevent healthcare-associated infections and provide safe, quality resident care). This failure had the potential to result in infection and/or spread of infection within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be free of medication error rates of five percent or greater when two medication errors were observed out of 30 opportunities. The medication error rate was calculated as follows: two divided by 30 then multiplied by 100 which was equal to 6.67 percent The errors were: 1. Resident 2 received a crushed tablet of cinacalcet hydrochloride (HCl) (used to treat a condition of excess hormones produced by the parathyroid, a gland in the neck). 2. Resident 2 received a crushed tablet of delayed release omeprazole (used to treat heartburn). The failure to administer tablets according to manufacturer's guidelines, which specifically state not to crush the tablets, had the potential to result in decreased effectiveness of the medications.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective antibiotic stewardship program (optimizes treatment of infections while reducing risk of adverse events related to antibiotic use and monitors facility-wide antibiotic use). The failure to ensure the facility had an individual with designated responsibility for the infection control program and antibiotic use protocols had the potential to result in overuse of antibiotics and increased antibiotic resistance (the reduced effectiveness of an antibiotic against specific organisms).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of seven sampled residents (Resident 86) a toothbrush and toothpaste for two days. This failure resulted in Resident 86 not being able to brush his teeth and had the potential to result in inadequate oral hygiene.