Inspection·December 13, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some event. RN 1 stated the NS had called the Medical Doctor (MD) and Family Representative (FR) about Resident 5 receiving unprescribed medications. During a review of Resident 5's nursing progress notes dated 7/8/23 at 10 a.m., the notes indicated, 0800 pt [patient, Resident 5] was given [Resident 1's] medications while eating her breakfast. The medications given were: Alogliptin Benzoate Oral Tablet 12.5 MG [milligrams] (Alogliptin Benzoate) for DMZ [diabetes], Cymbalta Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCI) for pain management r/t [related to]neuropathy (nerve pain), Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) for seizure disorder, Enalapril Maleate Oral Tablet 2.5 MG (Enalapril Maleate) for HTN [hypertension, known as high blood pressure], Jardiance Oral Tablet 10 MG (Empagliflozln) for DMZ, QUEtiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) for . visual hallucination. Pt reports dizziness. Noticed 1 episode of feeling drowsy MD notified .send to ER [emergency room] for close monitoring. Called 911 for ambulance to come During a review of Resident 5 ' s, Physician Order Summary dated 7/8/23, the Summary indicated an order, OK to send patient to hospital for evaluation. During a review of Resident 5 ' s hospital document titled, ED (emergency department) Triage (order of priority) Note, dated 7/8/23 at 10:07 a.m., the ED Triage Note indicated Resident 5 was received in the ED for receiving wrong the wrong medications at the skilled nursing facility. The Note indicated, Pt (patient) feeling sleepy. During a review of Resident 5 ' s hospital document titled, H&P (history and physical), dated 7/08/23 at 1:07 p.m., the H&P indicated the Chief Complaint: Accidental Medication .presents with accidental overdose . admit for overnight observation. During a review of Resident 5 ' s, Physician Order Summary, dated 7/10/23, the Physician Order Summary indicated an order to admit Resident 5 to the facility. During an interview on 8/21/23 at 09:48 a.m., with the Director of Nursing (DON), she stated she expected all licensed staff to follow the 10-rights of medication administration. During a concurrent interview and record review on 8/21/23 at 12:30 p.m., with the DON, the documents titled, Inservice Education Record for Medication Administration and Med Error Prevention (Medication Pass Review) Attendance Sheets, dated 7/12/23 and 7/18/23 were reviewed. The in-service records indicated, .Resident must be identified prior to administration .the nurse administering the medication must also ensure the resident swallows the medication before the nurse may leave. All doses of all medication passes must be observed as being consumed by the resident in the presence of the nurse passing the medication . During a review of the facility ' s policy titled Medication Administration, dated 2007, indicated, .Residents should be observed swallowing all medications 2. During a review of Resident 2 ' s admission Record, undated, the admission Record indicated Resident 2 was admitted to the facility in July 2023 with a diagnosis of hypertension (high blood pressure). During an observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 8/21/23 at 8:27 a.m., LVN 1 walked into Resident 2 ' s room carrying medications in a medicine cup. The medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 2 of 6 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 12/13/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some included glipizide (used to stimulate the release of insulin from the pancreas) 5 mg (milligram, a unit of measurement) tablet, plavix (used to prevent blood clots) 75mg tablet, atorvastatin (used to reduce the risk of heart attack and stroke) 80mg tablet, and pantoprozole (used to treat heartburn) 40 mg tablet. LVN 1 handed the medication cup to Resident 2, who swallowed the medications. LVN 1 stated she had not checked any resident identifiers before giving the medications to Resident 2 because she knew all her residents. LVN 1 stated the policy was to check resident identifiers before administration of medications. 3. During a review of Resident 4 ' s admission Record, undated, the admission Record indicated Resident 4 was admitted to the facility in 2022, with a diagnosis of muscle weakness. During an observation and interview with Licensed Vocational Nurse 3 (LVN 3) on 8/21/23 at 8:49 a.m., LVN 3 walked into Resident 4 ' s room carrying medications in a medicine cup. The medications included, Apixaban (used to prevent stroke) 5 mg (1 tablet), and Allopurinol (used to prevent or lower acid levels in blood) 100 mg 1 tablet. LVN 3 handed the medication cup to Resident 4, who swallowed the medications. LVN 3 stated she had not checked any resident identifiers before the medications were administered because the Medication Administration Record (MAR) had a picture of Resident 4, and she knew the resident. During an interview on 8/21/23 at 9:48 a.m., with the Director of Nursing (DON), the DON stated licensed staff had been trained on proper medication administration and were expected to check two resident identifiers prior to any medication administration. During a review of the facility ' s policy titled Medication Administration, dated 2007, indicated, .10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include a) Check identification band, b) Check photograph attached to medical record, c) Verify resident information with other nursing care center personnel. Note: the resident ' s room number or physical location is not used as an identifier FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 3 of 6 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 12/13/2023 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, for one of four sampled residents (Resident 5), the facility failed to ensure nursing staff followed policy and procedures to prevent significant medication errors when nursing staff failed to use resident identifiers (Information directly associated with a person that reliably identifies the individual as the person for whom the service or treatment is intended) to check Resident 5 ' s identity before leaving six medications not prescribed for Resident 5, on Resident 5 ' s bedside table. Residents Affected - Some These failures resulted in Resident 5 taking the six unprescribed prescription medications (quetiapine as a mood stabilizer/depression treatment, empagliflozin for high blood sugar/heart failure, enalapril for high pressure/heart failure, divalproex for seizures/mood stabilizer, duloxetine for depression, and alogliptin for high blood sugar) left at her bedside. The unprescribed medications caused Resident 5 to have dizziness, drowsiness, and required two days in acute care hospital to monitor for potentially life-threatening adverse consequences such as low blood sugar, low blood pressure, heart arrhythmias (irregular heart rhythm) and excessive sedation (which can result in breathing difficulties). See also tag F 755 Findings: During a review of Resident 5 ' s admission Record, undated, the admission Record indicated Resident 5 was admitted to the facility in June 2023, with a diagnosis of diabetes (a chronic disease caused by high levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves), asthma (difficulty in breathing), and muscle weakness. During an interview on 8/21/23, at 9:36 a.m., with Registered Nurse (RN) 1, RN 1 stated, on the morning of 7/8/23, she had taken medications to Resident 5 ' s room and placed the medications on Resident 5 ' s bedside table. RN 1 stated she left Resident 5 ' s room to document Resident 5 ' s medication administration and noticed she had given medications prescribed for another resident. RN 1 returned to Resident 5 ' s room and Resident 5 said she had already taken the medications left on the bedside table. RN 1 stated she was in a hurry that morning and did not use two patient identifiers prior to leaving the medications at the bedside or review the medications with Resident 5. RN 1 stated she had told Resident 5 that she had taken six medications that belonged to another Resident. RN 1 stated after Resident 5 took the medications, RN 1 had informed the Nursing Supervisor (NS) of the event. RN 1 stated the NS had called the Medical Doctor (MD) and Family Representative (FR) about Resident 5 receiving unprescribed medications. During a review of Resident 5's nursing progress notes dated 7/8/23 at 10 a.m., the notes indicated, 0800 pt [patient, Resident 5] was given [Resident 1's] medications while eating her breakfast. The medications given were: Alogliptin Benzoate Oral Tablet 12.5 MG [milligrams] (Alogliptin Benzoate) for DMZ [diabetes], Cymbalta Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCI) for pain management r/t [related to]neuropathy (nerve pain), Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) for seizure disorder, Enalapril Maleate Oral Tablet 2.5 MG (Enalapril Maleate) for HTN [hypertension, known as high blood pressure], Jardiance Oral Tablet 10 MG (Empagliflozln) for DMZ, QUEtiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) for . visual hallucination. Pt reports dizziness. Noticed 1 episode of feeling drowsy MD notified .send to ER [emergency room] for close monitoring. Called 911 for ambulance to come (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 4 of 6 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 12/13/2023 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 8/21/23 at 9:48 a.m., with the Director of Nursing (DON), the DON stated licensed staff had received in-service and training in July of 2023 on the 10-rights of medication administration. The DON stated nurses were expected to check two resident identifiers prior to any medication administration. During a phone interview on 8/21/23 at 1:35 p.m., with Resident 5 ' s physician (MD), MD stated he was told Resident 5 received the wrong medications on 7/8/23. MD further stated he was most concerned about Resident 5 having received Seroquel and Depakote as they could cause significant side effects, such as inadequate breathing and increased fall risk from the dizziness Resident 5 experienced. During a review of Resident 5 ' s, Physician Order Summary dated 7/8/23, the Summary indicated an order, OK to send patient to hospital for evaluation. During a review of Resident 5 ' s hospital document titled, ED (emergency department) Triage (order of priority) Note, dated 7/8/23 at 10:07 a.m., the ED Triage Note indicated Resident 5 was received in the ED for receiving wrong the wrong medications at the skilled nursing facility. The Note indicated, Pt (patient) feeling sleepy. During a review of Resident 5 ' s hospital document titled, H&P (history and physical), dated 07/08/23 at 1:07 p.m., the H&P indicated the Chief Complaint: Accidental Medication .presents with accidental overdose . admit for overnight observation. During a review of Resident 5 ' s, Physician Order Summary dated 7/10/23, the Physician Order Summary indicated an order to admit Resident 5 to the facility. During a review of the Daily Med (National Institute of Health, National Library of Medicine website) label for quetiapine, dated 8/18/22, the Daily Med indicated quetiapine should be used for treatment of certain mental disorders (including depression). The Daily Med indicated quetiapine had a boxed warning (the strongest warning the Food and Drug Administration has for a significant risk of serious or even life-threatening adverse effects). The adverse side effects included high blood sugar and increased risk of death for elderly patients with dementia (memory, thinking, language, judgment, or behavior problems). Further record review of the Daily Med indicated the following adverse effects as follows: - empagliflozin dated 6/22/23, indicated empagliflozin was used for treatment of heart failure and the control of blood sugar. The adverse side effects included dehydration (insufficient water and fluids for the body ' s needs) and low blood sugar. During a review of Daily Med label for enalapril dated 10/4/10, the Daily Med indicated enalapril was used for the treatment of high blood pressure; adverse side effects included low blood pressure. During a review of Daily Med label for divalproex dated 2/1/23, the Daily Med indicated divalproex was used for the treatment of seizure disorders and mental disorders causing symptoms of abnormally and persistently elevated, expansive, or irritable mood (mania). Divalproex had a boxed warning for increased risk of liver failure with death. Other side effects include sleepiness in the elderly, and risk of death from pancreatitis (inflammation of the pancreas). During a review of Daily Med label for duloxetine dated 8/18/23, the Daily Med indicated duloxetine was used for treatment of depression and chronic pain in muscles and bones. The Daily Med indicated duloxetine had a boxed warning for increased risk of suicide among young adults; other adverse effects included increased risk of falls due to sudden blood pressure drop upon standing, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 5 of 6 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 12/13/2023 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)

F 0760 potentially fatal liver failure. Level of Harm - Minimal harm or potential for actual harm During a review of Daily Med label for alogliptin dated 9/20/22, the Daily Med indicated alogliptin was used to treat high blood sugar. The Daily Med indicated adverse side effects included low blood sugar, and allergic reactions. Residents Affected - Some A review of facility policy titled, Medication Administration, dated 2007, indicated .10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include a) Check identification band, b) Check photograph attached to medical record, c) Verify resident information with other nursing care center personnel. Note: the resident ' s room number or physical location is not used as an identifier . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 6 of 6