Inspection·January 9, 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 a resident was free from physical abuse when Resident 2 punched her roommate (Resident 1) on the left arm with her right hand. This failure had the potential for physical injury from retaliation in response to the roommates's aggressive behavior. Findings: Review of Resident 1's admission Record, dated 10/19/23, indicated Resident 1 had a diagnosis of Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances and schizophrenia (a mental disorder in which a person loses touch with reality). Review of the clinical record for Resident 1, the Minimum Data Set (MDS-a comprehensive assessment tool) dated 8/10/23, indicated Resident 1 had severe memory and judgement impairments. Review of Resident 1 ' s Care Plan, indicated Resident 1 had behavior problems of saying profanities and throwing things on the floor. Review of Resident 1's interdisciplinary team (IDT, staff from different departments who coordinate the resident ' s care) notes dated 10/19/23, indicated, Resident 1 threw a glass of milk to her roommate and her roommate hit Resident 1 ' s left arm. The IDT notes also indicated; Resident 1 was at risk for behavioral changes related to roommate hitting her on the left arm. During a phone interview on 12/5/23, at 11:29 a.m., with Certified Nursing Assistant (CNA) 1, stated, on 10/19/23, she was helping Resident 2, who was in lying in her bed, to be cleaned up. Stated, at that time, Resident 1 was also lying in her bed and was beside Resident 2. Stated, she stepped out of the room for a minute and when she reentered the room, Resident 2 was reaching to Resident 1 and was punching Resident 1 in the left arm with her right hand while saying, I want to beat your ass, I want to kill you. Also stated, Resident 2 told her that Resident 1 threw milk at Resident 2. CNA 1 stated, she saw that the lower right-side of Resident 2 ' s bed was wet with milk and there was an empty glass on the floor. During an interview with Resident 2 on 12/5/23 at 1:49 p.m., Resident 2 admitted that she hit Resident 1 ' s left arm with her right hand because Resident 1 threw a glass of milk at her. Stated she did not want Resident 1 to throw more things at her. (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 01/09/2024 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)