Health inspection·June 25, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to perform a thorough investigation and report for seven of nine residents (Residents 1, 2, 3, 4, 5, 11, and 12). Residents Affected - Few This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety. Findings: During a review of the 5-day investigation summary of an alleged altercation between Residents 2 and 3, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the altercation did occur, or not. During a review of the 5-day investigation summary of an alleged altercation between Residents 1 and 2, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the altercation did occur, or not. During a record review and concurrent interview on 5/7/24 at 4:14 p.m., with the Minimum Data Set Nurse (MDSN), she reviewed the Interdisciplinary Team (IDT, a group of healthcare professionals from different fields that work together towards common goal for a patient) notes and confirmed that there was no conclusion for the alleged altercation between Residents 1 and 2. During a review of the 5-day investigation summary of an alleged altercation between Residents 4 and 5, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the altercation did occur, or not. During an observation and concurrent interview on 5/7/24 at 4:14 p.m., with the MDSN, she reviewed the IDT notes and confirmed that there was no conclusion for the alleged altercation between Residents 4 and 5. During a record review and concurrent interview on 5/7/24 at 4:50 p.m., with the administrator (ADM), the ADM reviewed the facility's 5-day follow-up for the incidents. The ADM stated the follow-up investigations were not thorough, not clear. He was not able to verify if the allegations were substantiated or not. The ADM also stated the facility's 5-day follow-up investigation for the incidents had not followed their abuse P&P. A review of the facility's, undated, policy and procedure (P&P) titled Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, the P&P indicated, All reports of resident abuse .are reported to local, state, and federal agencies .and thoroughly investigated by facility Page 1 of 5 555068 555068 06/25/2024 White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128

F 0610 Level of Harm - Minimal harm or potential for actual harm management. Findings of all investigations are documented and reported. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. Residents Affected - Few 555068 Page 2 of 5 555068 06/25/2024 White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure three of three resident (Residents 8, 9, and 10) were kept free from constipation when physicians orders were not followed for interventions according to the facility's policy and professional standards. This failure caused each resident to become unnecessarily constipated. Residents Affected - Few Findings: Review of Resident 8's clinical record indicated she was admitted with diagnoses which included hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), constipation, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 8's bowel movements (BMs) documentation in the medical record, it indicated that Resident 8 did not have a BM from 5/9/24 - 5/12/24. During a review of Resident 8's physician orders, the orders indicated the following: 1. Milk of Magnesia (MOM) suspension 400 MG (a dosage strength of medication)/5 ML (an amount of liquid) Give 30 ml by mouth every 24 hours as needed for no bowel movements in two days, administer 30 ml daily as needed. 2. Dulcolax Suppository 10 mg (Bisacodyl) Insert one suppository rectally as needed for constipation daily as needed if MOM is ineffective and no BM in 24 hours. 3. Fleet enema 7-19 gm (dosage strength)/118 ml (Sodium Phosphates) Insert one dose rectally daily as needed if MOM and Dulcolax are ineffective and no BM in eight hours. During a review of Resident 8's Medication Administration Record (MAR), the MAR indicated she did not receive the following: 1. MOM from 5/1 - 5/16/24. It was discontinued after 5/16/24. 2. Bisacodyl suppository until 5/12/24. 3. Fleet enema until 5/15, when she was administered two Fleet enemas instead of one, as indicated by the physician order. Review of Resident 9's clinical record indicated she was admitted with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and need for assistance with personal care. During a review of Resident 9's BMs documentation in the medical record, it indicated that Resident 9 did not have BMs from 5/5-5/9, 5/14-5/17 until 3:49 a.m., and 5/24-5/27 until 8:15 p.m. During a review of Resident 9's physician orders, the orders indicated the following: 555068 Page 3 of 5 555068 06/25/2024 White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128

F 0658 1. MOM suspension 400 MG/5 ML Give 30 ml by mouth as needed for constipation once a day. Level of Harm - Minimal harm or potential for actual harm 2. Mineral oil enema insert one application rectally as needed for constipation once a day. Residents Affected - Few 3. Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally as needed for constipation (if MOM is ineffective). During a review of Resident 9's MAR for the month of May 2024, the MAR indicated she did not receive the following: 1. MOM for the month of May 2024. 2. Mineral oil enemas in the month of May 2024. 3. Dulcolax Suppositories in the month of May 2024. Review of Resident 10's clinical record indicated he was admitted with diagnoses which included anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), atrial fibrillation (an irregular and often very rapid heart rhythm), and chronic systolic heart failure (the left ventricle of your heart, which pumps most of the blood, has become weak). During a review of Resident 10's BMs documentation in the medical record, it indicated that Resident 10 did not have BMs from 5/26-5/29 until 1:51 p.m. During a review of Resident 10's physician orders, the orders indicated the following: 1. Bisacodyl Suppository 10 mg Insert one suppository rectally as needed for constipation daily as needed for constipation daily if MOM is ineffective. 2. Fleet enema 7-19 gm (dosage strength)/118 ml (Sodium Phosphates) Insert one dose rectally as needed for constipation daily if Dulcolax suppository is ineffective. 3. Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth as needed for constipation daily. During a review of Resident 10's MAR for the month of May 2024, the MAR indicated he did not receive: 1. MOM for the month of May 2024. 2. Fleet enemas in the month of May 2024. 3. Bisacodyl Suppositories in the month of May 2024. During an interview on 6/6/24 at 1:57 p.m. with licensed vocational nurse A (LVN A), she stated with no BM after 48 hrs, Resident 9 should have been considered constipated. LVN A stated, for constipation, MOM would be the first thing given, then suppository if MOM does not work. After looking in Resident 9's MAR, LVN A stated, neither MOM nor mineral oil enema were recorded as given in May. She also stated, with no BM on 5/14 & 5/15, she would have been considered constipated. LVN A stated 555068 Page 4 of 5 555068 06/25/2024 White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128

F 0658 there should be a report given if residents do not have a BM for 48 hours, but she had not checked it. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/6/24 at 2:22 p.m. with certified nursing assistant B (CNA B), she stated she reports to the nurse if residents have not had a BM after 2 days, at the end of the shift. The nurses will also check in the computer. Residents Affected - Few During an interview on 6/6/24 at 3:01 p.m. with the director of nursing (DON), he stated, the CNAs report the BMs in [name of electronic health record] and the nurse was responsible to check. The nurses will look in the computer, and also ask the CNAs to clarify. If 48 hours without a BM, the nurse should ask the CNA and the resident. Then follow orders for constipation protocol. During a review of the facility's undated policy and procedure (P&P) titled Bowel Management Protocol, the P&P indicated, Normal bowel pattern is once every day up to once every three (3) days. The nurse will review the resident flow record daily and compose a list of those residents not having had a BM in three (3) days. The nurse will provide medication as ordered by the physician or obtain a physician's order. The medication given should be recorded on the MAR. 555068 Page 5 of 5