Inspection·March 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/27/2025 at 12:21 p.m. the Maintenance Director (MD) stated he had only been made aware of an issue with Resident 51's bed on 3/24/2025. He then switched the bed out that night. Review of the document Resident Rights - Accommodation of Needs dated 10/1/2023, showed the purpose was To ensure that the Facility provides an environment and services that meet residents' individual needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 2 of 21 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 03/27/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 the facility failed to provide reasonable accommodations and/or alternative measures to address visual deficit (partial or total inability of visual perception) for one sampled resident (Resident 112). Residents Affected - Few This failure caused Resident 112 to become tearful and feel worthless. Findings: A record review of Resident 112 's admission record, printed on 3/26/25, indicated Resident 112 was admitted to the facility on [DATE]. During a record review of Resident 112 ' s Minimum Data Set (MDS, an assessment used to guide care) dated 3/1/25, it indicated Resident 112 had moderately impaired vision. The MDS assessment indicated Resident 112 ' s Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 15 out of 15, score for intact cognition. The assessment indicated Resident 112 required supervision and/or hand over hand assistance with eating and oral hygiene. The assessment indicated Resident 112 had diagnosis of cataracts (clouding of the normally clear lens of the eye), glaucoma (group of eye conditions that can cause blindness) or macular degeneration (eye disease that causes vision loss). During an observation on 03/25/25 at 12:02 p.m., Resident 112 had lunch tray in front of her. Resident 112 became tearful and used call light to request assistance in setting up meal tray and opening serving dishes. No large print of monthly calendar, daily menu, nor alternative menu were observed in Resident 112 's room. During an interview on 03/25/25 at 12:14 p.m., Resident 112 stated her left eye was completely blind and had limited vision in the right eye. Resident 112 stated the staff do not provide menus that she can read. Resident 112 also stated she felt worthless when she did not have a menu to guide her on the choice of foods that were available to her. During an interview on 03/26/25 at 02:07 p.m. Social Services Director (SS2) stated Resident 112 should have a magnifying glass, large print reading materials, and additional night light to accommodate visual deficit. SS2 stated dim lighting does not allow her to see the contents of her meal tray to ascertain she was not served with food which she disliked or was allergic to. During an observation and concurrent interview on 03/26/25 at 02:44 p.m.with Licensed Vocation Nurse (LVN 5), LVN5 stated Resident 112 had left eye impairment with limited right eye functionality. Certified nursing assistants and nursing staff should explain the food set up on the meal trays using the clock method, and provide assistance as needed until Resident 112 completes her meal. LVN5 stated postings should be within Resident 112's range of vision. LVN5 confirmed Resident 112's room did not have large print posting of monthly menu, and alternative menu. LVN5 stated Resident 112 should be given a a copy of the menu and alternate menu in large print and placed at a specific side of her bed where she could readily reach for it. During an observation and concurrent interview on 03/26/25 at 02:51 p.m. Resident 112 sat in her wheelchair which was a foot and a half away from the wall where the alternate menu was posted. She was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 3 of 21 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 03/27/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few straining to read the posting and admitted she could not read the posting as it was beyond her range of vision, During a record review of Resident 112 ' s untitled care plan dated 2/22/25, it indicated Resident 112 had impaired visual function related to glaucoma. The care plan goal was: resident will be comfortable and safe in her environment and interventions listed were: alter the environment for visual assistance. Review of an untitled Care Plan dated 2/24/25 indicated Resident 112 required visual aids (large prints), Resident 112 prefers to have her room and things arranged to promote independence, and staff will consistently tell Resident 112 where essential items are placed. During record review of the facilities policy and procedure (P&P) titled Resident Rights-Accommodation of Needs, dated 10/1/23, the P&P read: Residents ' individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and review on an ongoing basis .in order to accommodate residents ' individual needs and preferences, Facility staff will assist residents in maintaining independence, dignity and well-being to the extent possible according to residents ' wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 4 of 21 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 03/27/2025 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the skilled nursing facility staff did not accurately assess the needs for one of 26 sampled residents (Resident 51). Resident 51 had difficulty eating with poor-fitting dentures and impaired vision due to broken eyeglasses. This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment dated 2/27/2025, showed under the section Natural Teeth and Dentures, staff had not checked the appropriate boxes which would indicate Resident 51 had no natural teeth or dentures. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Oral/Dental Status showed he had No natural teeth or tooth fragment(s) and had Mouth or facial pain, discomfort or difficulty with chewing. Review of the section Hearing, Speech, and Vision showed Resident 51 used Corrective Lenses. Review of the document Inventory of Personal Effects dated 2/27/2025, showed Resident 51 entered the facility at that time with upper and lower dentures. On 3/24/2025 at 10:15 a.m. Resident 51 was observed to have no teeth. In a concurrent interview he stated he owned dentures but they were Hard to eat with. He stated he felt Frustrated that staff had not helped him address the issue with his dentures. During an interview on 3/24/2025 at 10:50 a.m., the Director of Social Services (SS2) stated she was unaware Resident 51 had dentures that did not fit properly. During an interview on 3/26/2025 at 12:30 p.m. Licensed Vocational Nurse 4 (LVN 4) stated she had never seen Resident 51 with teeth and did not report it because she Never thought it was an issue. There was no documentation in the clinical record which showed staff had addressed the fact that Resident 51 had no teeth and was not using his dentures. During an interview on 3/24/25 at 10:15 a.m. Resident 51 stated he had seizures and broke his glasses in October. He stated he could not see this surveyor as his vision was Blurry and he was frustrated since staff had not assisted him in obtaining an eye appointment. Resident 51 stated he had reported this to staff but Nothing happens. During a second interview at 1:30 p.m. Resident 51 stated he had been unable to see for the entire time he had been at the facility and it brought him back to high school when he was Too [NAME] to get glasses. He stated he has started to be able to identify staff by How they walk and the Outline of their body. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 5 of 21 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 03/27/2025 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 0636 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/24/2025 at 10:50 a.m. the SS2 stated she not been aware of any issues with Resident 51's vision and typically nursing staff would report this to her. During an interview on 3/26/2025 at 12:30 p.m., LVN 4 stated she had not been made aware of any issues with Resident 51's vision. Residents Affected - Few During an interview on 3/26/2024 at 12:40 p.m. Certified Nursing Assistant (CNA 4) stated she was not aware of any issues with his vision. There was no documentation in the clinical record which showed Resident 51's poor vision had been addressed. Record review of the document Order Entry dated 3/24/2025 showed a referral was made to an ophthalmologist for Resident 51. Review of the document RAI process (Resident Assessment Instrument) dated 10/1/2023, showed the purpose was To ensure the RAI is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 6 of 21 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 03/27/2025 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 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, the facility failed to ensure for one out of 26 sampled residents (Resident 88), foot care on a regular basis. Resident 88 had long, thickened, and cracked toenails, and his feet and ankles had layers of scaly dry skin. This failure resulted in Resident 88's feelings of well-being being affected due to lack of foot care. Residents Affected - Few Findings: A review of the facility's admission Record indicated Resident 88 was admitted on [DATE] with diagnoses that included failure to thrive. Resident 88's Minimum Data Set (MDS - resident assessment tool) dated 2/5/2025, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 14, (BIMS score of 13 - 15, cognitively intact). Resident 88's MDS Section GG- Functional Abilities for Self-Care indicated Resident 88 needed partial to moderate assistance for shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene During a concurrent observation and interview with Resident 88 on 03/24/25 at 11:25 a.m., in his room, Resident 88 stated he had long toenails, and it hurt when he put on his shoes. Resident 88 removed his socks, and pieces of dried flaky skin came out of his socks and feet. Resident 88's feet and ankles were severely dried with layers of scaly skin that dropped when he moved. Resident 88's toenails were thick, jagged and cracked. Resident 88's left foot toenails were thick and curved inward, which caused Resident 88 pain. Resident 88 stated he was offered shower, but he refused since it's very cold, and he wore three layers of socks. Resident 88 stated no one had checked his feet since he was admitted . Resident 88 stated he was told he could see a podiatrist, but it may take months for an appointment, and he will be going home soon. During a concurrent observation and interview on 3/24/25 at 11:40 a.m., at Resident 88's room with Director of Nurses (DON), DON looked at Resident 88's feet and agreed that Resident 88's feet and ankles had layers of severely dried skin and toenails which were overgrown. DON stated Resident 88 was offered shower, but he refused. During an interview on 03/24/25 at 01:40 p.m., with Resident 88, Resident 88 stated he asked a nurse to get his toenails trimmed, but he was instructed to see the social services, and request to get an appointment to see a podiatrist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 7 of 21 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 03/27/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the skilled nursing facility's licensed nursing staff did not provide care according to professional standards for 2 of 26 sampled residents (Residents 90 and 111). Residents 90 and 111 had elevated blood pressures that were not treated with available medication or reported to the doctor. Residents Affected - Few This resulted in the potential for a stroke. (bleed or clot in the brain) Findings: Record review of the document admission Record showed the facility admitted Resident 90 on 1/24/2025. Diagnoses included End Stage Renal Disease. During an interview on 3/25/2025 at 2:55 p.m. the Director of Nursing (DON) stated the dialysis center had called on 3/15/2025 to ask that Resident 90's blood pressure medication be adjusted as his blood pressure became too low at dialysis. The DON stated the medication was changed to prn (as needed) as opposed to regularly scheduled. Record review of the document Order Summary Report dated 3/25/2025 showed Hydralazine (blood pressure medication) was to be given by mouth every 8 hours as needed for SBP greater than 170. (SBP: systolic blood pressure - top number of a blood pressure reading) Review of the document Weights and Vitals Summary (WVS) dated 3/25/2025 showed Resident 90's blood pressure on 3/18/2025 was 176/92. Review of the document Progress Notes *New* dated 3/1/2025 to 3/25/2025 showed on 3/18/2025 Resident 90 was given Hydralazine which lowered his blood pressure to 149/74. Further review of the WVS showed Resident 90's blood pressure was 198/94 on 3/19/2025. There was no documentation which showed a second blood pressure had been taken. Review of the Medication Administration Record (MAR) showed no Hydralazine had been given on 3/19/2025. In a concurrent interview on 3/19/2025 at 3:22 p.m. the DON confirmed there was no further blood pressure check, hydralazine given, or doctor notified. The DON stated the doctor should have been called because it was a change in condition which could lead to a stroke. Record review of the WVS showed on 3/21/2025 at 7:04 a.m. Resident 90's blood pressure was 183/84. There was no documentation in the MAR which showed hydralazine had been given or the doctor notified. In a concurrent interview the DON confirmed the elevated blood pressure had not been treated and no call was made to the doctor. The DON stated she would have Expected staff to call. Record review of the WVS showed Resident s 90's blood pressure was 178/85 at 3:59 a.m. on 3/25/2025. There was no documentation in the MAR which showed hydralazine had been given. There was no documentation the doctor had been notified. In a concurrent interview on 3/25/2025 at 2:55 p.m. the DON confirmed hydralazine had not been given and the doctor notified. The DON stated They should have called. Record review of the document admission Record showed the facility admitted Resident 111 on 2/26/2025. Diagnoses included Atherosclerosis of Coronary Artery Bypass Grafts. (heart disease) Record review of the document Order Summary Report dated 3/26/2025 showed staff were to notify the doctor for an SBP greater than 140. Resident 111 was on Losartan and Carvedilol medications to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 8 of 21 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 03/27/2025 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 0684 control blood pressure. Level of Harm - Minimal harm or potential for actual harm Review of the WVS document showed the following blood pressures for Resident 111: 171/101 on 3/3/2025 at 7:38 a.m. Residents Affected - Few 167/96 on 3/3/2025 at 8:08 a.m. 175/108 on 3/3/2025 at 11:42 p.m. 155/95 on 3/4/2025 at 7:37 a.m. 166/81 on 3/24/2025 at 6:58 a.m. There was no documentation in the clinical record which showed the doctor had been notified for the elevated blood pressures. In a concurrent interview on 3/26/2025 at 11:40 a.m. the DON confirmed there was no documentation the doctor had been notified. Record Review of the document Blood Pressure, Measuring dated 9/2010, showed Hypertension should be reported to the physician. Review of the document Change of Condition Notification dated 10/1/2023, showed the purpose was To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 9 of 21 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 03/27/2025 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the skilled nursing facility did not make an appointment to assess poor vision for one of 26 sampled residents (Resident 51). Resident 51 had broken his glasses and could not adequately see. Residents Affected - Few This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment 5.4 dated 3/6/2025, showed Resident 51 had Adequate vision without the use of corrective lenses. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Hearing, Speech, and Vision showed Resident 51 used Corrective Lenses. During an interview on 3/24/25 at 10:15 a.m. Resident 51 stated he had seizures and broke his glasses in October. He stated he could not see this surveyor as his vision was Blurry and he was frustrated since staff had not assisted him in obtaining an eye appointment. Resident 51 stated he had reported this to staff but Nothing happens. During a second interview at 1:30 p.m. Resident 51 stated he had been unable to see during his entire stay in the facility and it Brings him back to high school when he was too [NAME] to get glasses. He stated he has started to be able to identify staff by How they walk and the Outline of their body. During an interview on 3/24/2025 at 10:50 a.m. the Social Services Director (SS2) stated she not been made aware of any issues with Resident 51's vision and typically nursing staff would report this to her. During an interview on 3/26/2025 at 12:30 p.m., Licensed Vocational Nurse 4 (LVN 4) stated she had not been made aware of any issues with Resident 51's vision. During an interview on 3/26/2024 at 12:40 p.m. Certified Nursing Assistant 4 (CNA 4) stated she was not aware of any issues with his vision. Record review of the document Order Entry dated 3/24/2025 (survey start date) showed a referral was made to an ophthalmologist for Resident 51. Review of the document RAI process (Resident Assessment Instrument) dated 10/1/2023, showed the purpose was To ensure the RAI is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 10 of 21 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 03/27/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 99), Resident 99's head of the bed (HOB) was elevated at a minimum of 30 degrees during tube feeding administration. This failure had a potential to affect Resident 99's health due to accidental inhalation of stomach contents to lungs. Findings: A review of facility's admission Record indicated Resident 99 was admitted on [DATE], with diagnoses that included protein-calorie malnutrition and cancer of upper opening of the stomach. Resident 99's Minimum Data Set (MDS - resident assessment tool) dated 12/18/2024, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 00, (BIMS score of 00 - 07, severe impairment). During a review of Resident 99's physician's Order Summary Report (OSR) for the month of 3/2025 indicated Enteral Feed Order two times a day Nocturnal feeding: Jevity (complete balanced nutrition formula) 1.2 cal @ 65 ml (millimeter)/HR x 20 HRs [hours] VIA PUMP/JTUBE . (jejunostomy tube -tube placed through the abdominal wall to the midsection of the small intestine). Furthermore, Resident 99's physician OSR indicated Elevate HOB to 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after feeding stopped. During a concurrent observation and interview on 03/24/25 10:53 A.M., Resident 99 was lying on her right and she slid down towards the middle of the bed. Resident 99's HOB was slightly elevated but less than 30 degrees. Resident 99's tube feeding was infusing at 65 ml/hr. Certified Nursing Assistant (CNA) 1 stated Resident 99's HOB had to be least 75 to 90 degrees during tube feeding. CNA 1 stated she would raise Resident 99's HOB, and move Resident 99 towards the HOB. CNA 1 adjusted the bed to a flat position, and CNA 1 stated she would get someone to help her move Resident 99 back up towards the HOB. Resident 99 was lying flat, and her tube feeding was infusing. CNA 1 exited the room to find someone to assist her. CNA 1 came back to the room with CNA 2, and they lifted Resident 99 towards the HOB. CNA 1 then elevated Resident 99's HOB to at least 30 degrees. During an observation on 03/25/25 at 09:37 A.M., Resident 99's HOB was positioned to less than 30 degrees, with tube feeding infusing at 65 ml/hr. During a concurrent observation and interview on 03/25/25 at 09:43 A.M., with CNA 3, CNA 3 went to see Resident 99 in her room. CNA 3 stated she would raise Resident 99's HOB to 30 degrees. During a concurrent interview and record review on 03/25/25 at 03:29 at P.M., with Director of Nursing (DON), DON stated there was a physician's order to keep Resident 99's HOB to at least 30 degrees during feeding administration. DON reviewed Resident 99's care plan and stated the intervention was to keep Resident 99's HOB at least at 30 degrees during j-tube feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 11 of 21 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 03/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label medications and properly dispose of expired medications for two of 26 sampled residents (Residents 24 and 28): 1. Resident 24's one open inhaler (inhaler: a devise used for delivering medicines into the lungs through breathing) was used beyond the use by date. 2. Resident 28's one discontinued inhaler was found in the medication cart. This failure exposed Resident 24 in receiving an inhaler with questionable potency and efficacy. This failure also resulted in a lack of oversight for Resident 28's discontinued inhaler. Findings: 1. During a review of Resident 24's admission Record (information containing contact details, brief medical history at-a-glance) indicated, Resident 24 was admitted to the facility on [DATE]. During a concurrent observation and interview on 3/25/25, at 1:05 p.m., with Licensed Vocational Nurse (LVN) 2, while inspecting medication cart one, Resident 24 had one opened medication box which contained Wixela or fluticasone propionate and salmeterol powder 100/50 inhaler box which had an open date of 1/17/25. The box also indicated, to dispose the inhaler 30 days after removal from foil pouch (foil pouch was the wrapper of the inhaler). LVN 2 acknowledged that the inhaler should have been disposed after 30 days from the date when it was opened. Further stated, the risk of giving an expired medication was for the resident receiving the inhalation medications with less potency (Wixela is the brand name for fluticasone propionate and salmeterol powder. Wixela is a medication used as maintenance treatment of chronic obstructive pulmonary disease or COPD - a lung disease that causes difficulty or discomfort in breathing; 100/50 is a form of measurement). A review of Resident 24's monthly physician order, for March 2025, indicated an order dated 1/29/25 for Fluticasone-Salmeterol Inhalation Aerosol Breath Activated 100-50 mcg/act (fluticasone salmeterol), one puff inhale orally two times a day for COPD. During a review of Resident 24's Medication Administration Record (MAR) indicated; Fluticasone-Salmeterol Inhalation Aerosol Breath Activated 100-50 mcg/act or Wixela inhaler was last given on 3/25/25 at 9:00 a.m. During a telephone interview on 3/26/25 at 2:47 p.m., with the Consultant Pharmacist (CP), CP stated the facility should have followed the manufacturer's guidelines in discarding Wixela inhaler after it has been opened. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included COPD . During an observation on 3/25/25, at 1:05 p.m., with LVN 2, while inspecting medication cart one, Resident 28 had one opened medication box which contained Combivent Respimat or Ipratropium- Albuterol Inhalation Aerosol Solution 20-100 mcg/act inhaler. The box had an open date of 12/23/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 12 of 21 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 03/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Combivent Respimat is the brand name for Ipratropium- Albuterol. Combivent Respimat is a medication used as a treatment of COPD; 20-100 mcg/act is a form of measurement). Review of Resident 28's Physician's order dated 12/16/24, indicated an order of Ipratropium- Albuterol Inhalation Aerosol Solution 20-100 mcg/act (Ipratropium- Albuterol) one puff inhale orally every six hours as needed for shortness of breath, wheezing and cough. This order was discontinued by the physician on 12/17/24. During a telephone interview on 3/26/25 at 2:47 p.m., with the CP, the CP stated, medications should be removed by the licensed nurses from the medication carts once the medications have been discontinued by the physician. A review of the facility's policy and procedure (P&P) titled, Medication Storage, Storage of Medications, dated 9/2018, the P&P indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . 14. Outdated, contaminated, discontinued or deteriorated medications . are immediately removed from stock, disposed of . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 13 of 21 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 03/27/2025 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the skilled nursing facility's staff did not set up a dental appointment for one of 26 sampled residents (Resident 51). Resident 51 had no natural teeth and had poor fitting dentures. Residents Affected - Few This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment, dated 2/27/2025 showed, under the section Natural Teeth and Dentures, nothing had been checked off to indicate he had no teeth or dentures. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Oral/Dental Status showed he had No natural teeth or tooth fragment(s) and had Mouth or facial pain, discomfort or difficulty with chewing. Review of the document Inventory of Personal Effects dated 2/27/2025, showed Resident 51 entered the facility at that time with upper and lower dentures. On 3/24/2025 at 10:15 a.m. Resident 51 was observed to have no teeth. In a concurrent interview he stated he owned dentures but they were Hard to eat with. He stated he felt Frustrated that staff had not helped him address the issue with his dentures. During an interview on 3/24/2025 at 10:50 a.m., the Director of Social Services (SS2) stated she was unaware Resident 51 had dentures that did not fit properly. During an interview on 3/26/2025 at 12:30 p.m. Licensed Vocational Nurse 4 (LVN 4) stated she had never seen Resident 51 with teeth and did not report it because she Never thought it was an issue. Review of the document RAI process (Resident Assessment Instrument) dated 10/1/2023, showed the purpose was To ensure the RAI is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 14 of 21 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 03/27/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to assist one out of three sampled residents (Resident 73) obtain Medi-Cal authorization for dental services in a timely manner.This failure had the potential to cause Resident 73 to be without dentures longer than necessary, which could result in weight loss, unhappiness, and stress. Residents Affected - Few Findings: During a review of Resident 73's admission Record, dated 3/27/25, Resident 73 was admitted to the facility on [DATE] with multiple diagnoses including homelessness, depression, and hypertension (high blood pressure). During an interview on March 24, 2025 at 11:55 a.m. with Resident 73, Resident 73 stated his teeth were removed several months ago, he wanted dentures, and he did not understand what was happening with his dental insurance. Resident 73 stated he was feeling very stressed about dental insurance and that if he understood about the share of cost, he would not have consented to have his teeth removed. Resident 73 stated not having teeth or dentures makes him feel like crap. During an interview on March 25, 2025 at 3:35 p.m. with Licensed Vocational Nurse 1 (LVN1), LVN1 stated when Resident 73 came back from having his teeth removed she was surprised because the facility did not know he was going to the dentist to have his teeth removed. During a concurrent interview and record review on March 25, 2025 at 3:35 p.m. with LVN1, Resident 73's progress note dated 3/6/25 at 17:49 was reviewed. LVN1 stated the progress note indicates she called Resident 73's dentist and dental insurance on 3/6/25 to try to assist Resident 73 understand what was happening with his dentures. LVN1 stated the resident asked her for help and was upset because he did not have dentures. During a concurrent interview and record review on 3/25/25 at 4:07 p.m. with Social Services Designee 2 (SS2) the Progress Notes for Resident 73 dated 1/14/25 to 3/25/25 were reviewed. The Progress Notes indicated Resident 73's teeth were removed on 1/14/25. SS2 stated on 3/6/25 she wrote a note stating that she contacted the dentist to discuss the share of cost of $1884 for dentures for Resident 73 and the dentist referred SS2 to call Denti-Cal (dental insurance for people on Medi-Cal). SS2 stated the reason for the delay between Resident 73's teeth being removed on 1/14/25 and her contacting the dentist on 3/6/25 was because it wasn't known by the facility that there was going to be a share of cost because Resident 73 was enrolled in Mastercare (an agency that assists residents discharge from skilled nursing facilities). During a concurrent interview and record review on 3/26/25 at 12:10 p.m. with SS2, an email from Mastercare to SS2, dated 3/4/25, was reviewed. SS2 stated the email was the first time the facility became aware that the resident had a share of cost for his dentures. SS2 stated usually the facility would coordinate dental work and insurance, but in this circumstance, Mastercare facilitated the dental work. SS2 stated there is no list of things that Mastercare handles instead of the facility. SS2 stated there could have been better communication between the facility and Mastercare in coordinating care for Resident 73. During an interview on 3/26/25 at 3:21 p.m. with the facility administrator (ADM), ADM stated the facility is liable and responsible for all residents, including residents who are working with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 15 of 21 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 03/27/2025 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 0791 Level of Harm - Minimal harm or potential for actual harm Mastercare. ADM stated that there should be coordination and communication between Mastercare and social services regarding dental care and insurance for residents. ADM stated there is no contract between the facility and Mastercare. ADM stated there is currently no policy regarding how to communicate and coordinate services with Mastercare. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 16 of 21 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 03/27/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure pureed texture meal was prepared in a manner that is flavorful, appetizing, and with good nutritional value. Residents Affected - Some These failures had the potential to affect the resident's overall nutritional status. Findings: During a concurrent observation and interview on 03/26/25 at 01:02 P.M., with Dietary Supervisor (DS), one test plate of pureed texture food consisted of oven-roasted BBQ beef, pureed fresh zucchini and carrots, and cheddar biscuits. The pureed BBQ beef was light brown with dark brown BBQ sauce, pureed fresh zucchini and carrots was light green and looked like a slime (squishy sensory toy), and pureed cheddar biscuit was paper white. Pureed oven BBQ beef roast did not have a strong flavor of beef; the BBQ sauce which tasted vinegary over powered the flavor of the oven roasted BBQ beef. The pureed zucchini and carrots did not taste like vegetables, and the consistency and texture were gummy/slimy. Pureed cheddar biscuit did have any flavor, and the texture was starchy. During a concurrent observation and interview on 03/26/25 at 01:46 P.M., with Cook, [NAME] stated he prepared the pureed texture food for nine residents. [NAME] stated he used the Robot Coupe (food processor, that can hold 3.5 quartz). [NAME] stated he tasted the pureed oven BBQ beef roast, and [NAME] stated that it did not have a lot of flavors. [NAME] stated that there was not enough BBQ beef extra to use for pureed texture. [NAME] stated for cheddar biscuits, he added 12 portions of biscuit in the Robot Coupe processor, and mixed it with water and milk. [NAME] stated he added the liquid up to max up to fill line (3.5 quartz) of Robot Coupe food processor. [NAME] stated after the cheddar biscuit was pureed, he transferred it in a bin, and he added thickener. [NAME] was not able to say the amount of thicker he used, but stated he added enough thickener until it was scoopable. [NAME] stated for zucchini and carrots, he added water until the max fill line of the food processor. [NAME] transferred the purred zucchini and carrots to a bin and added the powder thickener until its scoopable. During an interview on 03/27/25 at 09:27 A.M., with DS, DS stated [NAME] used the oven roasted BBQ beef drippings to add flavor to the pureed food, the drippings had a lot of fat/oil, so the cook probably added water. During a review of facility's recipe titled Pureed (IDDSI [ International Dysphagia Diet Standardization Initiative] Level 4) Meats indicated Directions: . 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth and gravy. For 12 servings, the amount of liquid needed was 12 to 24 ounces. The choice of liquid listed were Warm liquid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid . Furthermore, the recipe indicated If needed: Stabilizer: instant potato, non-fat dry milk breadcrumbs, toast, instant cream of rice or farina, or commercial instant thickener listed the amount of 6 to 12 tablespoons for 12 servings. During a review of facility's recipe titled Pureed (IDDSI Level 4) Vegetables indicated Directions: . 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk) if needed . For 12 servings, the amount of liquid needed was 2 to 6 ounces. The choice of liquid was Warm fluid such as milk, or low sodium broth, There are suggested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 17 of 21 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 03/27/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete amounts and may vary from vegetable to vegetable. Some vegetables man not require any liquid at all. Furthermore, the recipe indicated If needed: Stabilizer: instant potatoes or commercial instant food thickener. During a review of facility's recipe titled Pureed (IDDSI Level 4) Breads, Cakes, Cookies, . and Other Bread Products indicated Directions: . 2. Puree on low speed adding milk gradually. See above recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 3. Add stabilizer to increase density to the pureed food, if needed. Breaded items may not need stabilizer . For 12 servings amount of cliqued needed was 12 to 24 ounces. The choices of cliqued listed were Warm milk or cold milk if product is to be served cold. Furthermore, the recipe indicated If needed: Stabilizer: instant potato, non-fat dairy milk, or commercial instant food thickener. Event ID: Facility ID: 056213 If continuation sheet Page 18 of 21 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 03/27/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food served was palatable and at proper temperature. The oven BBQ beef roast was dry and non-tender, the vegetables were bland, and cheddar biscuit was dry. These failures had the potential to affect resident's well-being due to lack of enjoyment, satisfaction, and decrease in nutrients from their meals. Residents Affected - Some Findings: During an interview on 03/24/25 at 10:48 A.M., with Resident 115's Responsible Party (RP)1, RP 1 stated Resident 115 had been eating a lot less because he did not like the food. RP 1 stated Resident 115 enjoyed soup, salad, fruit, and fish. During an interview on 03/24/25 at 11:21 A.M., with Resident 33, Resident 33 stated she did not like the food because it was either cold or bland to taste. During an interview on 03/25/25 at 12:14 P.M., with Resident 112, Resident 112 stated she did not like the food in the facility because it was always cold, bland, and no variety. During an interview on 03/25/25 at 12:17 P.M., with Resident 371, Resident 371 stated she was not happy with the food since it was always served cold. During an interview on 03/24/25 at 12:53 P.M., with Resident 7, Resident 7 stated she did not like the food the facility offered because it was nasty, cold, unappealing, overcooked, and lacking nutrients. During an interview on 03/24/25 at 10:45 A.M., with Resident 29, Resident 29 stated the facility served the same food all the time, and it's like cat food, mushy and bad. Resident 29 added the facility used a lot of canned food. During an interview on 03/24/25 at 11:17 A.M., with Resident 31, Resident 31 stated food from the facility was not good and not appetizing. Furthermore, Resident 31 added the food was yuck. During a concurrent observation and interview on 03/26/25 at 11:36 A.M., in the kitchen with Cook, [NAME] checked the food temperature: oven BBQ beef roast at 168 ° (degrees) Fahrenheit (F), zucchini and carrots at 141° F, mashed sweet potato at 161° F, cheddar biscuit at 190° F, pureed zucchini and carrots at 182 ° F, pureed beef at 146 °F, and pureed cheddar biscuit at 156 ° F. During an observation on 3/26/25 at 12:05 P.M., in the kitchen, the first cart of food tray was sent out to the large dining room. The last cart of food tray was sent out of the kitchen at 12:54 P.M. During a concurrent observation and interview on 03/26/25 01:02 P.M., during test tray sample with Dietary Supervisor (DS), there were two plates served. First plate had oven BBQ beef roast at 151° F, zucchini and carrots at 131° F, and mashed sweet potato at 156 ° F. Second plate had pureed oven BBQ beef roast at 151.6 ° F, pureed zucchini and carrots at 137.6 ° F, and pureed cheddar biscuits at 137.7 ° F. The oven BBQ beef roast was non-tender and dry, the BBQ sauce had a strong flavor of vinegar, zucchini and carrots had a strong margarine flavor, but lack of dill flavor, and cheddar biscuits was dry. DS stated the facility used frozen carrots and canned sweet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 19 of 21 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 03/27/2025 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 0804 potatoes. Level of Harm - Minimal harm or potential for actual harm During a review of facility's Recipe: Fresh Zucchini and carrots indicated Ingredients: Fresh carrots, fresh zucchini, margarine, melted, drill, dried . Serve on trayline at the recommended temperature of 160°F 180° F or less. Residents Affected - Some During a review of facility's Recipe: Mashed Sweet Potatoes indicated Ingredients: Fresh or frozen sweet potato, peeled, cubed, water for boiling, milk, margarine. Serve on trayline at the recommended temperature of 160 °F - 180° F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 20 of 21 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 03/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store and prepare food in safe and sanitary manner when, large baking sheet trays with ground meat patties were not fully covered and stored near fresh vegetables, and foods were stored without identifying labels and use-by-dates. These failures had the potential for contamination of food resulting in food borne illness. Findings: During a concurrent observation and interview on 03/24/25 at 10:25 A.M., in the kitchen with Dietary Supervisor (DS), DS stated the facility had one reach-in refrigerator. In the reach-in refrigerator there was one container labeled beans with DM date: 3/16/25 and UBD: 3/21/25, DS stated the beans was past it's Use by date. There was another container did not have a label to identify it and open or use by date. DS stated the container labeled beans was kidney beans, and the other container without the identifying label was grape jelly. During a concurrent observation and interview on 03/24/25 at 10:35 A.M., in the walk-in refrigerator with DS, there were five large size baking sheet trays with ground meat patties covered with parchment paper. The baking sheets were stacked overlapping each other. Two of the five baking sheet trays were stacked on top of each other. The five baking sheet trays with ground meat patties were placed in the middle shelves, and baking sheet trays were placed on top of clear bins with vegetables. Above the baking sheet trays with ground meat patties were boxes of vegetables. DS said the baking sheet trays needed to be fully covered with plastic wrap. There was one opened juice bottle on the shelf, DS stated it was staff drink. There was an apple sauce cup, a single butter serving cup, and a lid were on the floor underneath the shelves. During a review of facility's policy and procedure titled Food Storage indicated Food items will be stored, thawed, and prepared in accordance with good sanitary practice. I. Raw Meat/Poultry/Seafood Storage Guidelines. A. Raw meat is to be stored separately from cooked meat . IX. Fresh Vegetable Storage Guidelines . C. Unwashed produce should not be placed in the refrigerator near ready to serve foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056213 If continuation sheet Page 21 of 21