Inspection·April 3, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hopeless. Resident 2 had no physical or verbal behavioral symptoms, such as hitting, kicking, pushing, screaming, cursing and threatening others. Resident 2 ' s diagnosis included schizophrenia (a disorder that affects a person ' s ability to think, feel and behave clearly) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 2's behavioral care plans, undated, indicated, Resident 2 had behavioral changes related to schizophrenia and dementia manifested by angry outbursts, yelling, screaming, not wanting visitors for roommate, not wanting to be greeted by another male resident, refusal of medication, physical and verbal aggression towards other residents. The care plan interventions included refer to behavioral treatment facility. During an interview on 4/3/24, at 1:53 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she heard Resident 2 yell at Resident 1 to get out of the hallway. LVN 1 said Resident 2 stated Resident 1 spat in her face and Resident 2 made threats to harm Resident 1. During an interview on 4/3/24, at 1:59 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 2 took a swing at Resident 1 and hit Resident 1 in the chest. CNA 1 further stated Resident 2 was upset that Resident 1 was in the hallway near Resident 2 ' s room. 2. Further review of Resident 2 ' s progress notes, dated 2/9/24, indicated Resident 2 joined other residents to play bingo game in the dining room. Resident 3 put one bingo card on top of Resident 2's card. Resident 2 got upset. Resident 2 asked for an empty box of chocolate and threw it at Resident 3. Resident 3 got upset, stood up and reacted by pushing the table. Resident 2 pushed back on the table which caused Resident 3 to lose balance and fall. Review of Resident 3's Minimum Data Set, dated [DATE], indicated Resident 3 ' s Basic Interview of mental status (BIMS) score was 13 (meaning cognitive intact). Resident 3 was not able to report correct day of the week. Resident 3 had episodes of feeling bad about himself. Resident 3's diagnoses included mood disorder. During an interview on 4/3/24, at 1:11 p.m., with Social Services Assistant (SSA), SSA stated while she assisted residents back to their rooms after the Bingo activity, Resident 2 pushed at the table. Resident 3 pushed back at the table, lost his balance and fell in the dining room. The facility ' s policy and procedure, titled, Abuse Prevention Policy and Prohibition Program, dated 10/1/23, indicated, each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. Based on interview and record review, the facility failed to ensure two (Resident 1 and 3) of three sampled residents were free from verbal and physical abuse when, 1. Resident 2 screamed, hit and made verbal threats to harm Resident 1 during an altercation in the hallway; and 2. Resident 2 threw an object at Resident 3 who reacted by pushing the table, lost his balance and fell at a bingo game in the dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 2 of 4 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 04/03/2024 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some This failure caused repeated resident-to-resident altercations, emotional distress and potential to result in injuries for residents in the facility. Findings 1. Review of Resident 2's progress notes dated 3/12/24 indicated Resident 2 screamed, hit and made verbal threats to harm Resident 1. Resident 2 was angry that Resident 1 was in the room next to Resident 2. Resident 2 demanded that Resident 1 leave her side of the hallway. During an interview with Resident 1, on 4/3/24, at 11:26 a.m., Resident 1 stated he went to visit one resident in the room next to Resident 2's room, when Resident 2 came out of her room and started screaming at him and made racist remarks at him. Resident 1 further stated Resident 2 hit him in the chest area. Resident 1 stated he was upset because he was not free to go where he wanted in the facility. During an interview with Resident 2, on 4/3/24, at 12:30 p.m., Resident 2 stated Resident 1 called her yellow and made racist remarks at her. Resident 2 stated she had a shouting match with Resident 1 because she was upset about the name calling and did not want Resident 2 coming around the hallway towards her room. Resident 2 stated Resident 1 spit in her face. Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 9/13/21, indicated Resident 1's Basic Interview of mental status (BIMS) score was 15 (meaning cognitively intact). Resident 1 had no behavioral symptoms. Resident 1's diagnosis included congestive heart failure. Review of Resident 2's Minimum Data Set, dated [DATE], indicated Resident 2's Basic Interview of mental status (BIMS) score was 15. Resident 2 had mood symptoms of feeling down, depressed or hopeless. Resident 2 had no physical or verbal behavioral symptoms, such as hitting, kicking, pushing, screaming, cursing and threatening others. Resident 2's diagnosis included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 2's behavioral care plans, undated, indicated, Resident 2 had behavioral changes related to schizophrenia and dementia manifested by angry outbursts, yelling, screaming, not wanting visitors for roommate, not wanting to be greeted by another male resident, refusal of medication, physical and verbal aggression towards other residents. The care plan interventions included refer to behavioral treatment facility. During an interview on 4/3/24, at 1:53 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she heard Resident 2 yell at Resident 1 to get out of the hallway. LVN 1 said Resident 2 stated Resident 1 spat in her face and Resident 2 made threats to harm Resident 1. During an interview on 4/3/24, at 1:59 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 2 took a swing at Resident 1 and hit Resident 1 in the chest. CNA 1 further stated Resident 2 was upset that Resident 1 was in the hallway near Resident 2's room. 2. Further review of Resident 2's progress notes, dated 2/9/24, indicated Resident 2 joined other residents to play bingo game in the dining room. Resident 3 put one bingo card on top of Resident 2's card. Resident 2 got upset. Resident 2 asked for an empty box of chocolate and threw it at Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 3 of 4 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 04/03/2024 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Resident 3 got upset, stood up and reacted by pushing the table. Resident 2 pushed back on the table which caused Resident 3 to lose balance and fall. Review of Resident 3's Minimum Data Set, dated [DATE], indicated Resident 3's Basic Interview of mental status (BIMS) score was 13 (meaning cognitive intact). Resident 3 was not able to report correct day of the week. Resident 3 had episodes of feeling bad about himself. Resident 3's diagnoses included mood disorder. During an interview on 4/3/24, at 1:11 p.m., with Social Services Assistant (SSA), SSA stated while she assisted residents back to their rooms after the Bingo activity, Resident 2 pushed at the table. Resident 3 pushed back at the table, lost his balance and fell in the dining room. The facility's policy and procedure, titled, Abuse Prevention Policy and Prohibition Program, dated 10/1/23, indicated, each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 4 of 4