Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shields Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple health issues continued to receive routine acetaminophen for pain management without reevaluation, despite ongoing assessments showing no pain. Physician-ordered lab tests were not completed, and required monitoring of fluid intake and output was not performed, even though the resident's intake was often below the recommended level. When a STAT urinalysis was ordered due to a change in condition, the nurse failed to notify the physician after unsuccessful attempts to obtain a specimen and did not document the actions taken, resulting in delayed care.
A resident's medical record was not accurately documented when an LVN failed to record a physician's STAT order for urinalysis and straight catheterization, including the date and time received. The LVN did not notify the physician of unsuccessful attempts to obtain a urine specimen or the resident's ongoing pain, and the order was not properly documented or communicated between shifts. The DON was unaware of the order's status, and the progress notes lacked critical timing information.
The facility did not report two residents who tested positive for COVID-19 to the health department, despite facility policy requiring such reporting. Interviews with the DON, Admin, and IP confirmed knowledge of the cases and the lack of reporting, with the IP later receiving instructions from public health to report all positive cases.
A resident council meeting was held in an empty resident room that could not accommodate all interested participants, with several residents in wheelchairs present. A resident reported discomfort with meetings being held in her room and noted that space was insufficient for group participation. The AD and Admin confirmed that meetings were held in empty rooms due to lack of a designated space, limiting resident involvement. Facility policy required provision of space and privacy for such meetings, which was not met.
The facility did not ensure that discussions about advance directives were documented in the medical records for several residents, including those with cognitive impairment and those who were cognitively intact. Review of records and staff interviews confirmed that required documentation and follow-up regarding advance directives were missing, contrary to facility policy.
The Consultant Pharmacist did not provide comprehensive onsite pharmacy services, as evidenced by loose pills found in a med cart, tube feeding formula stored under a hand washing sink, and a cabinet full of discontinued narcotics that had not been destroyed in a timely manner. The CP had not been physically present for medication reviews, drug destruction, or QA meetings, contrary to facility and pharmacy policy.
Surveyors found expired sour cream, a bag of soggy salad, and a dirty utensil holder in the kitchen, all of which were acknowledged by the Dietary Supervisor as not meeting facility policy and posing risks such as stomach upset and cross-contamination for residents receiving food from the kitchen.
A resident was unable to store perishable food brought by family due to the facility's lack of a refrigerator, despite facility policy requiring such storage. Both the ADON and DON confirmed that the refrigerator previously available for resident use had not been replaced after it broke, and families were told to only bring food for immediate consumption.
Two residents with a diagnosis of schizophrenia were not referred for a required PASRR Level II evaluation. Review of admission records and PASRR Level I screenings revealed that the necessary referrals were not made, and the DON and MDS coordinator were unaware of the requirement.
A resident receiving hospice care did not have a coordinated plan of care developed with participation from hospice representatives, the resident, or their representatives, as required by facility policy. Interviews with the SSD and DON confirmed that no care plan conference was scheduled and no collaboration occurred with hospice staff, resulting in the resident's hospice care plan lacking required input.
A resident with morbid obesity, hemiplegia, and hemiparesis, who required two-person assistance for bed mobility, was turned by a CNA without help, resulting in the resident falling from bed and sustaining a left femur fracture. Staff interviews confirmed the resident's need for extensive assistance, and the incident occurred when the bed was in a high position.
A resident's legal representative did not receive requested medical records within the required timeframe, as the facility delayed processing and mailing the documents for over forty days despite receiving a hand-delivered authorization request. The delay was due to miscommunication and lack of timely action by staff, in violation of facility policy.
A resident with dementia and a high risk for pressure ulcers developed a stage 3 sacral wound, but staff failed to consistently assess and document the wound as required. Facility records showed missing or incomplete weekly wound assessments, and interviews with the DON and an LVN confirmed that expected documentation practices were not always followed.
A facility failed to complete a comprehensive MDS assessment for a resident within the required timeframe. The MDSC acknowledged the delay was due to workload, and the assessment was still in progress at the time of the survey. Facility policy mandates timely assessments, which was not followed.
A facility failed to provide a resident with a 30-day notice of discharge and did not send a copy to the State Long-Term Care Ombudsman. The resident, with severe cognitive impairment and multiple diagnoses, was discharged home without proper notification and documentation procedures being followed.
A resident with severe cognitive impairment and multiple medical conditions was discharged without proper consideration of their needs, leading to re-admission to the hospital. The discharge plan did not account for the availability and capability of caregiver support, nor did it ensure the resident's diet requirements were met. The facility's policy and procedure for discharge planning were not followed, resulting in the resident falling multiple times and being sent back to the hospital.
Failure to Reevaluate Pain Medication, Complete Lab Orders, and Monitor Fluid Status
Penalty
Summary
The facility failed to provide necessary treatment and care services for a resident with severe cognitive impairment and multiple medical diagnoses, including non-Alzheimer's dementia and malnutrition. The resident was routinely administered acetaminophen twice daily for pain management, despite documentation over several months indicating no complaints of pain and regular pain assessments showing no pain. The care plan required reassessment of the need for pain medication, but this was not done, and the medication regimen continued without reevaluation, contrary to facility policy and professional standards. Additionally, the facility did not carry out physician-ordered diagnostic laboratory tests, including blood work, for the resident. The Director of Nursing confirmed that the laboratory tests ordered by the physician were not performed. The resident's care plan also required monitoring and documentation of fluid intake and output due to a risk for fluid deficit related to chronic urinary tract infection. However, daily fluid intake was not consistently tallied, output was not recorded, and the resident's intake was frequently below the minimum required amount, with no documentation to show that intake and output were monitored as required by the care plan and facility policy. When the resident experienced a change in condition, including abdominal pain and other symptoms, a STAT order for a urinalysis via straight catheterization was received. The nurse attempted to obtain the specimen twice without success but did not notify the physician of the failed attempts or document the order and actions taken. The STAT order was endorsed to the next shift without timely follow-up, and the Director of Nursing was unaware of the delay. The facility's policies required prompt communication with the physician and documentation of such events, which did not occur in this case.
Failure to Accurately Document and Communicate STAT Lab Orders
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurately documented and systematically organized according to accepted professional standards. Specifically, a Licensed Vocational Nurse (LVN) did not document a physician's order for a STAT urinalysis (UA) and straight catheterization, including the date and time the order was received. The LVN attempted to obtain a urine specimen by straight catheterization twice without success and endorsed the STAT order to the night shift nurse but did not notify the physician of the failed attempts or the resident's continued complaints of pain. The LVN also did not document the order for straight catheterization in the resident's medical record. Upon review of the resident's progress notes and laboratory reports, it was found that the documentation did not reflect the time the physician's order for STAT labs was received, and the Director of Nursing (DON) was unaware that the STAT lab order had been endorsed from shift to shift or that it was received a day before the resident was transferred to the hospital. The lack of proper documentation and communication regarding the physician's orders and the resident's condition contributed to the deficiency identified during the survey.
Failure to Report COVID-19 Outbreak to Health Department
Penalty
Summary
The facility failed to implement its policy and procedure for reporting an outbreak of communicable disease, specifically COVID-19. Two residents tested positive for COVID-19 in July 2025, with one resident being transferred to the hospital for shortness of breath and subsequently testing positive for COVID-19, and another resident's laboratory test confirming a positive result. Despite these cases, the facility did not report the outbreak to the local or state health department as required by their policy. Interviews with the Director of Nursing, Administrator, and Infection Preventionist confirmed awareness of the two positive cases but revealed that no report was made to the health department. The facility's policy, dated September 2022, defines an outbreak as even a single case of a highly communicable disease and assigns responsibility for reporting to the Administrator. The Infection Preventionist stated that the facility later received instructions from the county public health nurse to report all positive COVID-19 cases, but the initial cases were not reported as required.
Inadequate Space Provided for Resident Council Meetings
Penalty
Summary
The facility failed to provide adequate space for resident council meetings, as evidenced by observations and interviews. During a resident council meeting, six residents in wheelchairs were seated in an empty resident room, which was reported to be insufficient to accommodate all interested participants. One resident, who was cognitively intact and able to express her needs, stated that meetings were sometimes held in her room or other empty resident rooms, but these spaces were not large enough for all residents wishing to attend. She also expressed discomfort with having meetings in her personal room. The Activity Director confirmed that space was limited and that more residents would participate if a larger area were available. As a result, some meetings were conducted one-on-one in residents' rooms instead of as group sessions. The Administrator acknowledged that there was no specific room assigned for resident council meetings and that meetings typically took place in empty resident rooms. Review of the facility's policy indicated that the resident council should be provided with space, privacy, and support to conduct meetings, which was not being met at the time of the survey.
Failure to Document Advance Directive Discussions in Resident Records
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to document that advance directives were discussed with residents and/or their responsible parties. Specifically, for four out of fifteen sampled residents, there was no evidence in the medical records that advance directives were addressed as required. These residents included individuals with varying cognitive abilities, such as those who were cognitively intact and those with severe cognitive impairment due to conditions like dementia and Alzheimer's disease. In each case, reviews of admission records, Minimum Data Set (MDS) assessments, and Physician Orders for Life-Sustaining Treatment (POLST) forms showed either the absence of an advance directive or a lack of documentation regarding any discussion about advance directives. Interviews with facility staff, including the Social Service Director (SSD) and the Director of Nursing (DON), confirmed that there was no documentation of advance directive discussions or follow-up with the residents or their responsible parties. The facility's policy required that information about advance directives be provided and documented upon or prior to admission, and that the existence of such directives be prominently displayed in the medical record. However, this process was not followed for the identified residents, resulting in incomplete records regarding their wishes for medical treatment.
Consultant Pharmacist Failed to Provide Comprehensive Onsite Pharmacy Services
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) provided comprehensive consultation on all aspects of pharmacy services. During observations, loose pills were found in the medication cart, and multiple bottles of tube feeding formula were stored in a cabinet underneath a hand washing sink. The Registered Nurse (RN) present was unaware of the improper storage of both the loose pills and the formula. The Director of Nursing (DON) confirmed the improper storage and stated that there was a designated container for loose pills, expecting licensed nurses to dispose of medications properly. Additionally, a cabinet in the medication room was found to be full of discontinued narcotic medications, with the last destruction of these drugs by the CP occurring several months prior. The DON stated that the CP had been conducting medication reviews remotely and had not visited the facility to assist with the destruction of discontinued medications. The Administrator reported that the CP had been inconsistent with facility visits, continued remote reviews since the COVID-19 period, and had not attended quarterly Quality Assurance (QA) Committee meetings since 2022. The CP's Director of Clinical Operation was unaware of the lack of physical presence and stated that pharmacy policy required in-person visits for drug destruction and QA attendance.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
During an initial kitchen tour, surveyors observed two expired containers of sour cream stored in the kitchen refrigerator, one of which was opened and nearly empty. The Dietary Supervisor (DS) confirmed that the expired sour cream should have been disposed of and acknowledged the risk of stomach upset for residents if consumed. Additionally, an opened plastic bag of soggy salad was found in the refrigerator, which the DS also stated should have been discarded due to similar risks. Review of the facility's policy indicated that all perishable food items are to be stored properly, with open dates and use-by dates per manufacturer guidelines. Further observation revealed that the utensil holder used for storing kitchen utensils was not clean, with visible brownish stains and scattered brownish particles. The DS acknowledged the utensil holder was dirty and recognized the risk of cross-contamination from storing utensils in such a condition. Facility policy requires all kitchen equipment and surfaces that come in contact with food to be cleaned and sanitized after each use. The 2022 Federal Food Code also mandates that food-contact surfaces be clean to sight and touch, and free of food residue and debris.
Failure to Provide Refrigerator for Resident Food Storage
Penalty
Summary
The facility failed to provide a means for residents to store food brought in by family members, as evidenced by the experience of one resident who was unable to refrigerate food brought from home. During a resident council meeting, the resident reported that she had to consume the food immediately and share it with her caregiver because there was no refrigerator available for resident use. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed in interviews that the facility previously had a refrigerator for this purpose, but it had broken and was not replaced. Instead, families were instructed to only bring enough food for immediate consumption and to take any leftovers home. A review of the facility's policy and procedure on food brought by family or visitors indicated that perishable foods should be stored in resealable containers with tight-fitting lids in a refrigerator, labeled with the resident's name, item, and use-by date. However, the facility was not following this policy due to the lack of a refrigerator, resulting in the resident being unable to store perishable food items as intended. The resident involved was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS).
Failure to Refer Residents with Schizophrenia for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that two residents with a diagnosis of schizophrenia were properly screened and referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation, as required for individuals with mental disorders or intellectual disabilities. Record reviews showed that both residents had a documented diagnosis of schizophrenia at the time of admission, but their PASRR Level I screenings did not result in a referral for Level II evaluation. During interviews, the Director of Nursing and the MDS coordinator confirmed they were not aware of the need to refer these residents for further PASRR assessment.
Failure to Collaborate with Hospice for Resident's Plan of Care
Penalty
Summary
The facility failed to follow its hospice policy and procedure by not collaborating, developing, and implementing a coordinated plan of care (POC) with hospice representatives for a resident who was admitted into the hospice program. The resident, who had a principal diagnosis of a disorder of the brain, was admitted to the facility and started on hospice services. However, the resident's hospice POC did not reflect the participation of hospice representatives, the resident, or the resident's representatives, as required by facility policy and applicable regulations. Interviews with the Social Services Designee (SSD) and the Director of Nursing (DON) confirmed that no care plan conference had been scheduled with the hospice provider, and there was no collaboration with hospice representatives in developing the resident's hospice care plan. The SSD acknowledged awareness of the requirement but stated that the care conference had not been scheduled. The DON confirmed that the facility had not met to collaborate with hospice representatives on the resident's POC, attributing the failure to an oversight. Review of the facility's policy indicated that such collaboration and coordination were required for residents receiving hospice services.
Failure to Provide Required Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
Resident 14, who had diagnoses including morbid obesity, hemiplegia, and hemiparesis, required extensive assistance by two staff members for bed mobility and repositioning, as documented in the resident's care plan and Minimum Data Set (MDS). Despite these documented needs, a Certified Nursing Assistant (CNA) attempted to turn and reposition the resident alone, without requesting the required assistance. During this unsupervised care, the resident was rolled out of bed and fell to the floor, resulting in a left femur fracture. The resident's bed was also noted to be in a high position at the time of the fall. Interviews and record reviews confirmed that the CNA was aware of the need for a second person to assist but did not seek help. The resident was subsequently found screaming in pain and was transferred to the hospital, where the fracture was confirmed. Staff interviews further corroborated that the resident consistently required two to three persons for safe repositioning due to her condition, and the Director of Rehabilitation stated the fall was avoidable if proper assistance had been used.
Failure to Timely Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide a resident's representative with copies of the resident's medical records within the required forty-eight-hour timeframe after receiving a written request. The representative hand-delivered an authorization request for the records, which was received by facility staff. Despite this, the medical records staff did not promptly process the request, stating uncertainty about when the request was received and indicating that the request may have been left in the administrator's office. The medical records staff later confirmed to the representative that the request was still being processed several weeks after the initial submission. Ultimately, the requested documents were not mailed until forty-two days after the initial request, as confirmed by a USPS receipt. The facility's own policy required that such requests be fulfilled within forty-eight hours, excluding weekends and holidays. The delay in providing the records was due to a lack of timely communication and follow-through by both the medical records staff and the administrator, resulting in the representative not receiving the necessary documents within the mandated period.
Failure to Consistently Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and document a coccyx pressure ulcer for one resident with a history of dementia and a urinary tract infection. The resident was admitted with a low pain score and later developed a stage 3 pressure ulcer in the sacral region. Review of facility records showed inconsistent and incomplete documentation of weekly wound assessments and skin evaluations, with several dates missing required wound descriptions and skin section entries. The Braden Scale assessment indicated the resident was at very high risk for pressure ulcers, yet the documentation did not consistently reflect thorough wound monitoring. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that weekly wound assessments, including staging and detailed wound descriptions, were expected but not always completed or documented as required. Facility policy specified that all wound assessment data should be recorded in the resident's medical record, but this was not consistently done. The lack of regular and complete wound assessment documentation had the potential to delay identification of infection or changes in the wound's condition.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident within the regulatory specified timeframes. The resident was admitted to the facility, and the Admission MDS was not completed within 14 calendar days as required. The MDS Coordinator (MDSC) acknowledged that the Admission Assessment should have been completed by the specified date but was delayed due to the MDSC's workload. During an interview and record review, the MDSC confirmed that the Admission MDS was still in progress and not yet completed at the time of the survey. The facility's policy requires that the Assessment Coordinator ensures timely resident assessments, which was not adhered to in this case.
Failure to Provide Timely Discharge Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a resident with a notice of proposed discharge within the required timeframe of at least 30 days prior to the actual discharge date. Additionally, the facility did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman as required. The resident, who was admitted with multiple diagnoses including cerebral palsy, dysphagia, repeated falls, rhabdomyolysis, syncope, and dorsalgia, had a BIMS score indicating severe cognitive impairment. Despite this, the resident was discharged home without the proper notification and documentation procedures being followed. The Notice of Proposed Transfer/Discharge was signed by the caregiver on the same day as the discharge, which was only five days after the notification date, far short of the required 30-day notice period. During interviews, the Physical Therapist indicated that the resident still needed 24-hour care at the time of discharge, and the Administrator admitted to not knowing if the discharge notice was sent to the Ombudsman office. Furthermore, the facility lacked a policy and procedure addressing discharge notices, and no proof was provided that the notice was sent to the Ombudsman office.
Failure to Implement Effective Discharge Planning
Penalty
Summary
The facility failed to implement effective discharge planning for a resident who required 24-hour care. The resident, who had severe cognitive impairment and multiple medical conditions including cerebral palsy, dysphagia, and repeated falls, was discharged without proper consideration of their needs. The discharge plan did not account for the availability and capability of caregiver support, nor did it ensure the resident's diet requirements were met. This oversight led to the resident being re-admitted to the hospital shortly after discharge due to severe pain and repeated falls. Interviews and record reviews revealed that the resident's family had agreed to take the resident home only when they could use the bathroom independently. However, the resident still required significant assistance with activities of daily living (ADLs) and needed 24-hour care at the time of discharge. The Director of Nursing (DON) was unaware of the resident's need for 24-hour care, which would have altered the discharge plan to keep the resident in the facility for long-term care. Additionally, the caregiver did not attend training sessions, and the resident's discharge plan was not thoroughly reviewed by the interdisciplinary team. The facility's policy and procedure for discharge planning were not followed, as the discharge plan did not include a description of the resident's discharge goals, the degree of caregiver support, or factors that could make the resident vulnerable to readmission. The caregiver reported being unable to provide the necessary 24-hour care and stated that the resident fell multiple times after being discharged. The resident was eventually sent back to the hospital due to severe pain and repeated falls, highlighting the facility's failure to ensure a safe and effective discharge plan.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Cerrito
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chaparral House | 2.5 mi | ★★★★★ | 2 | 0 |
| Shields Richmond Nursing Center | 3.2 mi | ★★★★★ | 3 | 0 |
| Kyakameena Care Center | 3.2 mi | ★★★★★ | 26 | 0 |
| Elmwood Care Center | 3.5 mi | ★★★★★ | 8 | 0 |
| Ashby Care Center | 3.6 mi | ★★★★★ | 2 | 0 |
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