F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Resident 1 was admitted to
the facility in March 2021 with diagnoses that included Alzheimer's dementia (a loss of brain function that
occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language,
judgment, or behavior), severe open-angle glaucoma (group of eye conditions that damage the nerves in
the eye causing visual impairment), and type 2 diabetes mellitus (a long-term [chronic] disease in which the
body cannot regulate the amount of sugar in the blood).
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to
identify resident care problems to be addressed in an individualized care plan), dated 1/9/24, the MDS
indicated Resident 1 had impaired vision and had a Brief interview for Mental Status (BIMS, a scoring
system used to determine the resident's cognitive status in regard to attention, orientation, and ability to
register and recall information) score of nine (A BIMS score of nine is an indication of moderately impaired
cognitive response).
During a review of Resident 2's Face Sheet, undated, the Face Sheet indicated Resident 2 was admitted to
the facility in April 2011 with diagnoses that included intracranial injury (injury inside the confined area of
the skull), aphasia (loss of ability to understand or express speech, caused by brain damage), obesity, and
left hemiplegia (weakness of one side of the body).
During a review of Resident 2's MDS, dated 3/11/24, the MDS indicated Resident 2's BIMS score is 15 (an
indication of an intact cognitive response).
During a review of Resident 2's Progress Notes, dated 2/14/24, the Progress Notes indicated on 2/14/24
around 7:15 a.m., Certified Nursing Assistant (CNA) 1 saw Resident 2 Physically hit his roommate
[Resident 1] on both legs ., with slurred speech, Resident 2 stated being bothered by Resident 1's constant
calls.
During an interview on 3/7/24 at 11:50 a.m. with Resident 1, Resident 1 stated, while in bed, Resident 2
came over to Resident 1's bedside, growling and making noises. Resident 1 started tapping the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055292
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055292
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Shields Richmond Nursing Center
1919 Cutting Blvd
Richmond, CA 94804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
table next to the bed to signal staff to come to the room. Resident 1 stated, Resident 2 got annoyed by the
table tapping, and with a closed fist, hit Resident 1's left knee. Resident 1 stated he only felt safe in the
same room with Resident 2 when staff was around.
During a review of Resident 1's Skilled Evaluation (SE), dated 2/14/24, the SE indicated, Resident was
upset and afraid after being hit by [roommate] this morning.
During an interview on 3/7/24 at 11:55 a.m. with Resident 2, Resident 2 stated going over to Resident 1's
bedside after Resident 1 had refused to turn the light off. Resident 2 stated he was banging on Resident 1's
bed to make Resident 1 turn off the light.
During a review of Resident 2's SE, dated 2/14/24, the SE indicated Resident 2's Mood and Behavior as
agitated with No recent change in mood.
During a telephone interview on 3/7/24 at 1:06 p.m. with CNA 1, CNA 1 stated she responded to the call
light in Resident 1 and Resident 2's room before breakfast time on 2/14/24. CNA 1 stated Resident 2 had
asked CNA 1 to turn off the overbed light which CNA 1 did and left the room. CNA 1 stated, a few moments
later, the call light in Resident 1's room came on again. CNA 1 stated she went back to the room to find out
what the residents needed. CNA 1 stated, halfway through the hallway, CNA 1 could hear Resident 1
calling for help. CNA 1 stated, as she got to the room, CNA 1 saw Resident 2 sitting in the wheelchair by
Resident 2's bed and hitting Resident 1 in the legs. CNA 1 stated Resident 2 was shouting and appeared
very angry, Resident 2's right hand was balled up in a fist and he hit Resident 1's left leg. CNA 1 stated
Resident 2 was separated from Resident 1. CNA 1 stated this was not the first incident that Resident 2 got
involved in.
During a review of Resident 2's clinical record, the Progress Notes, dated 11/20/23, indicated a staff
member witnessed Resident 2 repeatedly hitting a roommate's back and twisting the roommate's wrist and
arm. The roommate was very confused and had gone under Resident 2's bed. Resident 2's roommate was
found to have two small skin tears on the left arm after the two residents were separated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055292
If continuation sheet
Page 2 of 2
