Shields Richmond Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was discharged in a safe manner to another skilled nursing facility when discharging facility did not receive confirmation of agreement to admit Resident 1 from the receiving facility before Resident 1 was discharged and transferred. This failure resulted in the inability for Resident 1 to be accepted for admission at the receiving facility and for Resident 1 being sent to the GACH emergency department. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services to maintain grooming and personal hygiene for one of three sampled residents (Resident 1) when; Resident 1 was not given showers as scheduled by the facility. This failure placed Resident 1 at risk for poor hygiene, body odor, infection, and transmission of diseases. During a review of Resident 1's admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/2/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIM score of fifteen is an indication of intact cognitive status.) score was 09 and indicated moderately impaired mental status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor. This failure placed facility residents at risk of unplanned weight loss, a consequence of poor food intake. During an interview on 3/5/26, at 10:45 a.m., with Resident 2, Resident 2 lay in bed in his room awake and verbally responsive. Resident 2 stated that he has his own stack of food kept at his bedside because sometimes the food served is not edible. Resident 2 stated, for example, French fries were hard and unable to be eaten, meat served for dinner was very tough. Resident 2 stated he was not able to cut the meat with a knife. Resident 2 stated he had reported to nursing staff and Dietary Supervisor (DS). During an interview on 3/5/26, at 11:52 a.m., with Dietary Supervisor (DS), DS stated she was recently hired. DS stated she was not aware of any food concerns. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 18, 33, 14 and 7), received activities of daily living (ADL) care when the following was noted: 1. Resident 18 had long fingernails with black matter underneath both hands. 2. Resident 33 had long fingernails with black matter underneath both hands. 3. Resident 14 had overgrown fingernails. 4. Resident 7, who was dependent on staff, was not turned and repositioned every two hours as indicated in the care plan.

Inspectors wroteBased on interview and record review, for three of 22 sampled residents (Resident 41, 20 and 5), the facility failed to provide treatment and care in accordance with professional standards of practice when: 1. Resident 41 did not receive multiple medications that included anti-hypertensives (blood pressure lowering medications), stool softeners and phosphate binders, according to physician's orders. This failure had the potential for complications that included hypertensive emergency (a severe and immediate medical condition characterized by dangerously high blood pressure and signs of end-organ damage, such as to the brain, heart, or kidneys), and hyperphosphatemia (or high phosphorus levels in the blood, a common and serious complication in patients with end-stage renal disease (ESRD). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent for three out of eight sampled Residents (Resident 25, 57, and 270). This failure had the potential for negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices when two expired medications in a medication cart were available for use. These failures had the potential to result in Residents receiving expired and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a qualified Dietary Services Manager (DSM) in the absence of a full-time Registered Dietitian (DC) for 64 Residents who received food from the kitchen. This failure had the potential for the residents' nutritional needs not to be met; and dietary staff were not supervised by a qualified person.

Inspectors wroteBased on observation, interview, and document review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. [NAME] 1 prepared food in the emergency three compartment sink. 2. Open package pasta was not stored in airtight container. 3. 12 Quart clear container stored multiple sprouted, soft, and wrinkled red potatoes. 4. Powdered sugar in tin can labeled with used by 4/10/25. 5. One and half pint cherry tomatoes was not labeled and dated with used by. 6. 12 Quart full container with wrinkled, mushed, liquified cherry tomatoes were stored. 7. Unlabeled 12 ounce (oz - unit of measurement) clear plastic container contained; a. four green bell peppers that were extremely soft with white fuzzy matter and discoloration; b. three wrinkled red bell peppers had caked in black matter and white fuzzy discoloration, two yellow peppers were wrinkled. 8. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide proper supervision to one of two Residents (Resident 1) during transfer from bed to wheelchair using Hoyer Lift [(a mechanical assistive device used by caregivers to safely transfer patients with limited mobility from one place to another (i.e. bed to wheelchair)]. This failure placed Resident 1 at risk for fall and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist in maintaining a sufficient food and fluid intake for one of three sampled residents (Resident 5) when Resident 5's poor meal and fluid intake were not addressed in a timely manner to maintain proper nutrition and hydration. This failure resulted in dehydration (dangerous loss of body fluid causes by illness or inadequate fluid intake) and potential for malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function) and further decline in Resident 5's health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when Registered Nurse (RN) 2, who failed to observe infection control procedures for contact precautions and identify a change in resident's bowel elimination status, did not complete annual competency/skills evaluation. This failure had the potential to result in unsafe resident care.

Inspectors wroteBased on observation, interview and record review, for one of one sampled resident (Resident 59) reviewed for psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication use, the facility failed to ensure Resident 59 received antipsychotic medication (treats mental disorders, including schizophrenia and bipolar disorder) with appropriate indication. This failure had the potential to result in unnecessary adverse reactions from the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention and control procedures were followed when: -Housekeeping Aide (HA) did not disinfect Resident 169's room, a contact precaution (a set of infection control practices used to prevent the spread of germs through direct or indirect contact. These precautions are implemented when a patient has a disease that can be transmitted by touching the patient, contaminated surfaces, or objects in their environment) room, with appropriate disinfectant. -Registered Nurse (RN) 1 did not disinfect medical device with appropriate disinfectant in between resident use. This failure had the potential to result in spreading Clostridium difficile (C. diff, a bacteria that causes diarrhea and colitis (inflammation of the colon). [...]

Inspectors wroteBased on interview and record review, for one randomly selected resident (Resident 369), the facility failed to establish and implement infection prevention and control program that included antibiotic stewardship program when: -Resident 369 was administered antibiotics without adequate indication. -Resident 369's possible symptoms of antibiotic side effects were not monitored. This failure had the potential to result in the development of antibiotic-resistant infections (occur when bacteria develop the ability to withstand the effects of antibiotics, making them difficult or impossible to treat, can be serious and even life-threatening, often requiring longer hospital stays, more expensive treatments, and potentially toxic medications).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 31 residents who occupied 12 multi-bed bedrooms. This deficient practice had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide dental services to meet the needs of two of three sampled residents (Resident 2 and Resident 3) when: 1. The facility failed to promptly refer Resident 2 for dental services, within three days as required, when Resident 2's tooth was chipped. 2. The facility did not provide timely dental services to obtain full dentures for Resident 3. These failures had the potential to result in decreased food intake and potential significant weight loss for both residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) was free from physical abuse when Resident 2 repeatedly hit Resident 1 on the left lower extremity. This failure had the potential to result in physical injury and psychosocial harm.

Inspectors wroteBased on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, and full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure kitchen staff were competent regarding job duties when: 1. A cook did not know the appropriate method for manually cleaning soiled utensils and equipment using the 3-compartment sink. 2. A diet aide did not know the appropriate procedures for testing the strength of the sanitizer solution used for sanitizing kitchen surfaces. 3. A diet aide did not demonstrate appropriate procedures for testing the sanitizer in the dish machine. These failures had the potential to result in contamination of kitchen equipment and/or utensils leading to illness caused by pathogens (harmful organisms) for 58 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure: 1. the menu met the nutritional needs of the residents; 2. there was a menu for a vegetarian diet; and 3. portions for diets provided matched what was indicated in the diet manual. These failures had the potential for residents to receive meals containing nutrients at levels not appropriate for their prescribed diet leading to food related medical complications for 58 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food that was palatable when food was bland (lacked flavor). This failure had the potential to negatively impact the residents' dining experience which may result in poor dietary intake compromising the health and nutritional status of 58 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to: 1. Provide an alternate vegetarian entrée of similar nutritive value to the regular entrée for one non-sampled resident (Resident 57). 2. Ensure peanut butter and jelly sandwiches offered as an alternate entrée were of similar nutritive value to the regular entrée. These failures had the potential to result in a decreased nutrient intake as indicated by the planned menu for 29 residents who received Regular textured food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when the following was noted: 1. A 10-pound roll of ground beef and a 10-pound package of sausage were not thawed safely. 2. A juice dispenser was not clean. 3. A can opener was not clean. 4. Three cutting boards were not in a good condition and were not clean. 5. Dry food was not stored at least six inches off the floor. 6. Three pans were in poor condition. 7. A lowerator (plate warmer) was not clean. 8. A fan mounted to the wall inside the kitchen was not clean. 9. A vent inside the dry food storage closet was not clean. 10. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to have a policy and procedure to describe how food brought in by family and visitors would be stored safely for the residents. This failure had the potential to negatively impact the residents' dining experience and possibly result in poor food intake for 58 residents who ate food by mouth.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of thirty-six sampled residents (Residents 24, 25, 56 and 215) had complete and current care plans. This failure had the potential to cause residents to not receive appropriate and adequate care thereby affecting their physical and psychosocial well-being. During a concurrent interview and record review on 12/6/23 at 7:58 a.m. with Director of Nursing (DON), Resident 25's care plans were reviewed. DON stated Res 25 was hospitalized from [DATE] to 10/5/23 and was diagnosed with pneumonia. DON further stated Res 25 received antibiotics from 10/5/23 to 10/7/23. DON stated Resident 25 did not have care plans for pneumonia and antibiotic treatment and without a care plan for antibiotics, the facility would not be able to check if the antibiotic was effective and monitor for side effects. [...]

Inspectors wroteBased on observation, interview, and facility document review the facility failed to ensure pureed food was the appropriate consistency. This failure had the potential for eight residents on pureed diet to aspirate (drawing food into the lungs) and/or negatively impact the residents' dining experience resulting in poor food intake compromising their nutritional status out of facility census of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff followed proper infection control precautions to prevent spread of infection for five (Resident 16, Resident 55, Resident 21, Resident 60, and Resident 167) of 58 sampled residents when: 1) Resident 167's urinary catheter bag was touching the floor. 2) The nasal cannula for Resident 55 was not changed weekly. 3) The tube feeding for Resident 60 was not dated and labelled. 4) Nursing assistant (NA) did not perform hand hygiene after providing incontinent care to Resident 21. NA did not perform hand hygiene before entering and exiting resident rooms. 5) Registered Nurse 2(RN 2) did not change gloves and perform hand hygiene after handling Resident 16's device, and then gave medications to Resident 16 and applied eye drops. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 30 residents who occupied 12 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside.

Inspectors wroteBased on interview and record reviews, the facility failed to meet the needs for one of two sampled residents (Resident 167) when the facility did not develop and implement a comprehensive care plan for Resident 167 with an indwelling urinary catheter (a tube that is inserted into the bladder to drain urine). This deficient practice placed Resident 167 at risk for developing physical and psychosocial complications related to use the of urinary catheters including infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 167) had a physician order to maintain an indwelling catheter (a tube inserted into the bladder that drains urine into a bag outside the body) in place after admission and indication of a medical condition for the use of the indwelling urinary catheter. This deficient practice placed Resident 167 at risk for developing complications related to use of urinary catheters including urinary tract infection.

Inspectors wroteBased on interview and record review, the facility failed to show an Interdisciplinary Team meeting was conducted after one sampled resident (Resident 19) had severe weight loss. This failure had the potential to result in inadequate resident care for one resident out of a census of 58.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan for dementia (progressive decline in memory that affects the ability to perform everyday activities) was developed for one of two sampled residents (Resident 167). This failure had the potential for Resident 167 to not receive the appropriate treatment and services needed to meet her dementia care needs.

Inspectors wroteBased on observation and interview, the facility failed to accommodate individual needs and preferences of one (Resident 31) of three sampled residents, when Resident 31 did not have access to dietary menu. This deficient practice had the potential to affect the quality of life for Resident 31 and his needs not being met while at the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to immediately report an alleged abuse allegation to the California Department of Public Health (CDPH) for over 24 hours for one (Resident 31) of 3 sampled residents when Resident 31 alleged CNA 3 touched him inappropriately. This failure had potential risk of delay in investigation and affect physical and psychological well-being of residents.

Inspectors wroteBased on interview and record review, the facility failed to complete quarterly Minimum Data Sets (MDS- an assessment tool used to quid care) timely for eight of ten sampled residents (Residents 10, 11,16, 24, 37, 40, 48, and 49). This failure had the potential to delay care planning and delivery.

Inspectors wroteBased on interview and record review, the facility failed to complete the annual Minimum Data Set (MDS- an assessment tool used in skilled nursing facilities), for one of ten sampled residents (Resident 9). This failure had the potential to delay care planning and care delivery.

Inspectors wroteBased on interview and record review, the facility failed to meet the needs for one (Resident 114) of one sampled residents receiving dialysis when the facility did not develop and implement care plan for Resident 114's dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) care. This deficient practice may result in Resident 114's physical, psychosocial and functional needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 61), of three sampled residents, received effective oxygen therapy when staff did not assess and monitor Resident 61's use of oxygen. This deficient practice may result in ineffective oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to provide care for one (Resident 114) that required dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) when staff did not do a complete assessment before Resident 114's dialysis treatment. This deficient practice resulted in an incomplete assessment of Resident 114's dialysis access site before their dialysis treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene between giving medications to two residents (Resident 21 and Resident 119) of 20 sampled residents This failure had the potential to cause or spread infections which can lead to hospitalization for Resident 21 and Resident 119, as well as the rest of the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 80 square foot of space per resident for 30 residents who occupied 12 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside.