Health inspection·August 19, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based observation, interview, and record review the facility failed to implement infection control practices for three of four emergency crash carts when: Residents Affected - Few 1. Emergency crash carts (crash cart is a set of trays/drawers/shelves on wheels used for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols to potentially save someone's life) B, and C contained oropharyngeal airway (OPA, also known as an oral airway is a medical device that helps maintain or keep a patient's airway open) kit that was not stored in the original packaging and was not labeled with shelf-life expectancy or no expiration date. 2. Emergency crash cart A contained oropharyngeal airway kit stored in two plastic bags had yellowish substance with no label or expiration date. 3. Emergency crash care B and C had one yankauer (Yankauer suction tips are often used to suction oropharyngeal secretions to prevent aspiration. They can be used in the mouth to remove excess fluid and secretions from people who have difficulty swallowing or spitting) and one adult nasal oxygen cannula (nasal cannula is a device that gives you additional oxygen- supplemental oxygen or oxygen therapy through your nose and It's a thin, flexible tube that goes around your head and into your nose) with no shelf-life expectancy or expiration date. These failures had the potential to spread infection and cross-contamination in the facility. Findings: 1. During an observation with the director of nursing on 7/12/24 at 12:08 p.m., emergency crash cart b and c contained oropharyngeal airway with no label or expiration date and was not stored in their original packaging. During a concurrent observation and interview with the infection control preventionist nurse (ICPN) on 7/12/24 at 12:20 p.m., the ICPN confirmed emergency crash cart B and C contained OPA with different sizes stored in two separate plastic bags. The first plastic bag had five pieces of OPA 50 millimeter (mm, is a unit of length in the International System of Units, equal to one thousandth of a meter), five pieces of OPA 60 mm, 70 mm, and 80 mm. The second bag had five pieces of 90 mm, 100 mm, and 110 mm. The ICPN confirmed the OPAs were not stored in their original packaging and the plastic bags did not have the OPAs shelf-life expectancy or expiration date. The ICPN further stated that the OPAs should have been stored in their original packaging for staff to know when the expiration date or shelf-life expectancy. (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: 555068 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 555068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128 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)