Health inspection·August 29, 2024

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 2) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions, and behavior) when Resident 2 received quetiapine fumarate (Seroquel, an antipsychotic medication used to treat certain mental/mood conditions) without adequate indication and monitoring a specific target behavior for its use. This failure could result in lack of adequate monitoring and had the potential for residents to receive unnecessary medications. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (loss of thinking, remembering, and reasoning skills) in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; type 2 diabetes mellitus (high levels of sugar in the blood) ; essential hypertension (high blood pressure that does not have a known cause). During a review of Resident 2's Minimum Data Set (MDS, a resident clinical assessment tool) dated 6/12/24, the MDS indicated, Resident 2 had a BIMS score of 99 (Brief Interview for Mental Status, a mandatory tool used to screen and identify the cognitive condition of residents. A score of 99 indicates that a patient was unable to complete the BIMS). During a review of Resident 2's nursing telehealth evaluation dated 6/7/24 9:49 p.m., indicated Resident 2's family member (FM) was requesting Seroquel because ER (emergency room) forgot to add that medication with discharge orders. During a review of Resident 2's physician order dated 6/7/24, it was indicated a new order for Seroquel 25 mg (milligram, unit of measurement) daily at bedtime for 3 days. The order did not have an indication for use and monitoring of side effects. During an interview on 7/26/24 at 4:12 p.m., with Licensed Vocational Nurse (LVN) B, she stated she went through the medication list with the FM and Seroquel was not in the list. LVN B stated the FM wanted Seroquel to ordered. LVN B stated she contacted the doctor and got an order for Seroquel. During a concurrent interview and record review on 8/21/24 at 9:25 a.m., with the Pharmacy (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 3 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 08/29/2024 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)