Health inspection·September 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for two of two sampled residents (Resident 1 and Resident 2), the facility failed to ensure a homelike environment with clean bed and bath linens that are in good condition when facility did not have enough towels and bed linens and used washcloths that had frayed edges. This failure resulted in an unfamiliar and uncomfortable environment for residents. Findings: During a review of Resident 1's admission Record, printed 9/15/23, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included pain in the right leg and the thoracic spine (upper and middle part of the back). 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 6/10/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 15. A BIMS score of thirteen to fifteen is an indication of intact cognitive status. During an interview with Resident 1 on 9/14/23 at 10:50 am, Resident 1 stated being able to perform personal hygiene tasks with some help from staff. Resident 1 stated the washcloths that were provided were small pieces that were torn or cut out from a towel and were worn out. Resident 1 stated the washcloths looked like rags. During a concurrent observation and interview on 9/14/23 at 11:30 a.m. with Personal Custodian (PC), the Storage E was observed. PC stated the towels, bed linens, and gowns were stored in that storage for residents. PC stated there were two linen storage closets for the unit. There were no towels or washcloths inside the storage. During a concurrent observation and interview on 9/14/23 at 11:41 a.m. with Maintenance Staff (MS), Storage Closet D was observed. The storage had no washcloths and no towels on the shelves marked with Towels, washcloth. MS stated clean laundry was delivered and stored in the storage closets at 6 am ready for use for the morning shift. MS stated, if there were no towels or wash cloths left, the staff should go to the laundry to ask for them. (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: 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 09/14/2023 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)