Health inspection·October 11, 2024

F 0880 were exposed. Level of Harm - Minimal harm or potential for actual harm -Four vital sign machines parked in the facility hallway contained plastic containers of [brand name] bleach. The four plastic containers of [brand name] bleach had open lids and the contents were exposed. Residents Affected - Some During a concurrent observation and interview on 10/10/24 at 11:06 a.m., with the director of staff development (DSD), he confirmed the above observations and stated that the lids of the [brand name] bleach should have been closed and should not be exposed. 2. During an observation on 10/10/24 at 11:01 a.m., CNA A was wearing gloves in the hallway walking room to room with the same gloves on and did not perform hand hygiene in between task. During a concurrent observation and interview on 10/10/24 at 11:02 a.m., with CNA A, she confirmed the above observations and stated she should have not used the same gloves in the hallway going room to room. She further stated that she should have performed hand hygiene in between task to prevent the spread of infection. During a concurrent observation and interview on 10/10/24 at 11:20 a.m., with CNA B, she confirmed that she used the same gloves in the hallway coming from the room of resident's that was assigned for her and did not perform hand hygiene after discarding used gloves in the garbage can outside the resident's room. She further stated that hand hygiene was important to prevent the spread of infection. 3. During a concurrent observation and interview with licensed vocational nurse C (LVN C) on 10/10/24 at 11:05 a.m., one box of clean gloves and one bottle of hand sanitizer were on top of a clean movable cart and were approximately 1/2 inch from a treatment cart with attached trash bin with an open lid. LVN C confirmed the observation and stated the clean gloves and the bottle of hand sanitizer should not be exposed to an open trash bin containing used pair of blue gloves, papers, two empty tubes. 4. During a concurrent observation and interview with the DSD on 10/10/24 at 11:07 a.m., three laundry hampers with three linens on top were stored outside by the facility's patio. The DSD confirmed the observation and stated that hampers should have been stored in the laundry area and there should be no linens on top of the hampers to prevent the spread of infection. 5. During a concurrent observation and interview with the environmental director (ED) on 10/10/24 at 11:08 a.m., a bin was overflowing with housekeeping towels outside the laundry area hallway. The ED confirmed the observation and stated the housekeeping towels should be stored in the bin with the lid closed. 6. During a concurrent observation and interview with the DSD on 10/10/24 at 11:14 a.m., two empty drinking water bottles, clean rolled plastic bags, one opened gloves and hand sanitizer were all stored together in a housekeeping cart that was parked in the hallway. The DSD confirmed the observation and stated the empty drinking water bottles should not be stored together with the clean housekeeping items to prevent contamination. 7. During a concurrent observation and interview with the DSD on 10/10/24 at 11:15 a.m., Resident 1's nasal cannula (tubing inserted into the nostrils and attached to an oxygen tank or concentrator) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555068 If continuation sheet Page 2 of 3 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 10/11/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was hanging and touching the wheelchair. The DSD confirmed the above observation and stated the nasal cannula should not be exposed and should not be touching the wheelchair. The DSD further stated Resident 1's nasal cannula should be stored in a black mesh bag. 8. During a concurrent observation and interview with the DSD on 10/10/24 at 11:17 a.m., red push cart with used meal trays and utensils were parked underneath the water and juice dispenser in the nursing station. The DSD confirmed the observation and stated the red pushcart are used for dirty trays and resident's [NAME] after they ate and should not be parked underneath the water and juice dispenser due to infection control issue. A review of the facility's undated policy and procedure (P&P), titled Handwashing/Hand Hygiene, the P&P indicated all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand- rub (ABHR) dispensers are placed in areas of high visibility and in patient care areas. Review of the facility's undated policy and procedure, titled Personal Protective Equipment- using Gloves, indicated when gloves are indicated, use disposable single -use gloves . perform hand hygiene after removing gloves. (note: Gloves do not replace hand hygiene) . Discard used gloves into the waste receptacle inside the examination or treatment room. Review of the facility's undated policy and procedure, titled Standard Precaution, indicated keep the oxygen cannula and tubing used in a pouch when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555068 If continuation sheet Page 3 of 3