Health inspection·March 7, 2024

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 Page 1 of 2 055292 055292 03/07/2024 Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

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. 055292 Page 2 of 2