Inspection·August 3, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for one of three sampled residents (Resident 2), who was dependent on staff for Activities of Daily Living (ADLs, such as transfers from bed to chair, bathing/showers, eating, personal hygiene), the facility failed to ensure showers were provided to maintain grooming and personal hygiene. Residents Affected - Few This failure had the potential to result in diminished self-esteem and poor grooming and personal hygiene. Findings: During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included muscle spasms, chronic pain, multiple sclerosis (chronic disease of the central nervous system, symptoms include trouble walking) and epilepsy (nerve cell activity in the brain is disturbed causing seizures). During a review of Resident 2's MDS (Minimum Data Set, a standardized assessment tool used for nursing home residents), dated 4/14/23, the MDS indicated Resident 2 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15 out of 15 indicating Resident 2 is cognitively intact. Resident 2 required staff assist with all ADLs that included transfers, toileting, dressing, and personal hygiene. During a review of Resident 2's ADL care plan (undated), the care plan indicated Resident 2 required assistance with ADLs and staff was to provide shower and body check on shower days. During a concurrent observation and interview on 8/3/23 at 1 p.m. with Resident 2, Resident 2 stated there had been a shortage of staff in the last five years at the facility. Resident 2 stated they have not gotten showers as scheduled because there were not enough CNAs that show up. Resident 2's hair appeared oily and matted. During an interview with Certified Nursing Assistant (CNA) 2 on 8/3/23 at 11:18 a.m., CNA 2 stated all residents are offered three showers weekly. CNA 2 stated when other CNAs called off, the assignment would be split among those who showed up, increasing the number of residents that each CNA would have. CNA 2 stated this would mean residents who were scheduled to have showers would have to fall in line. During a review of Resident 2's POC Response History Shower for July 2023, the document indicated Resident 2 received 4 out of 12 showers in one month. It also indicated Resident 2 went 14 days (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 6 Event ID: 056213 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 056213 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampico Healthcare Center 130 Tampico Street Walnut Creek, CA 94598 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)