Other·October 18, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated Survey for the investigation of complaint CA00607724. The inspection was limited to the specific complaint investigated and does not reflect the findings of a full inspection of the facility. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 38534.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 10/17/2018 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IC3G11 Facility ID: CA020000080 If continuation sheet 1 of 3 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055292 (X3) DATE SURVEY COMPLETED 10/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHIELDS RICHMOND NURSING CENTER 1919 Cutting Boulevard Richmond, CA 94804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to develop and follow a written policy to readmit one of three sampled residents (Resident 1) after hospitalization. Findings: Review of Resident 1's Admission Record indicated Resident 1 (a male resident) was admitted to the facility on 7/16/18. Review of the facility's nurses notes titled "Progress Notes" dated 8/21/18 at 11:16 p.m. indicated Resident 1 was transferred to the hospital following a fall. Record review of the ACH MD (Medical Doctor) Progress Notes dated 9/8/18, indicated that Resident 1 was "medically cleared for discharge, awaiting SNF (Skilled Nursing Facility) bed." Record review of the ACH Care Plan Notes Case Management dated 9/8/18, indicated that Resident 1 was scheduled to be discharged FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IC3G11 Facility ID: CA020000080 If continuation sheet 2 of 3 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055292 (X3) DATE SURVEY COMPLETED 10/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHIELDS RICHMOND NURSING CENTER 1919 Cutting Boulevard Richmond, CA 94804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE back to the nursing facility on 9/8/18, but the facility stated there was no open bed. During an interview with the Discharge Case Manager (DCM) on 10/15/18 at 3:30 p.m., the DCM stated Resident 1 was ready to be discharged from hospital to the facility on 9/8/18. Review of the facility's Daily Census dated 9/7/18 and 9/12/18 indicated the facility had three empty male beds on 9/7/18 and two empty male beds available on 9/12/18. During an interview with the Admission Department Marketing Director (ADMD) on 10/12/18 at 4:14 p.m., the ADMD stated they received a call from the hospital on 9/7/18 and 9/12/18 to readmit Resident 1 back to the facility. The ADMD did some investigation with the facility's staff and found out Resident 1 was high risk for fall, had some behavioral issues, and needed excessive care. The ADMD stated the facility's admission group decided not to readmit Resident 1 and informed the hospital team about their decision. During an interview with the facility's Administrator Assistant (AA) on 10/12/18 at 5:00 p.m., the AA stated Resident 1 had multiple falls and was not compliant with the physical therapists' instruction. During an interview on 10/15/18 at 2 p.m. the facility's Director of Nursing stated that she was not able to provide a policy for "returning the resident" at that time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IC3G11 Facility ID: CA020000080 If continuation sheet 3 of 3