Health inspection·November 21, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A letter from the State of California - Health and Human Services Agency Department of Health Care Services, dated 03/16/2022, revealed Resident #11's Level II evaluation was not completed, because Resident #11 had no serious mental illness. The letter directed the facility to submit a new Level I screening should the case need to be reopened. A Psychiatry Diagnostic Interview note, dated 06/08/2023, revealed Resident #11 had a primary psychiatric diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms and a secondary diagnosis of other psychotic disorder not due to a substance or known physiological condition. The note directed staff to add the diagnosis of psychotic disorder to the resident's record. Resident #11's medical record revealed no evidence of an updated Level I PASRR following the resident's new diagnosis of psychotic disorder in 06/2023. During an interview on 11/21/2024 at 12:54 PM, MDS Licensed Vocational Nurse (LVN) #3 said when Resident #11 received a new mental illness diagnosis, an updated PASRR should have been completed. During an interview on 11/21/2024 at 1:59 PM, the Director of Nursing (DON) stated a new PASRR should have been completed for Resident #11. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555068 If continuation sheet Page 2 of 5 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 11/21/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) Level I screenings accurately reflected the presence of diagnosed serious mental disorders and failed to ensure new PASRR Level I screenings were submitted on the 31st day of admission to the skilled nursing facility following an exempted hospital discharge for 2 (Resident #127 and Resident #25) of 6 residents reviewed for PASRR requirements. Residents Affected - Few Findings included: A facility policy titled admission Criteria, updated on 10/24/2024, specified, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) [another acronym for PASRR] process. a. The discharging hospital conducts a Level I PASARR screen for all potential Skilled Nursing Facility (SNF) admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. When/if the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative by the system for the Level II (evaluation and determination) screening process. 1. An admission Record indicated the facility originally admitted Resident #127 on 09/11/2024 and most recently admitted the resident on 10/07/2024. According to the admission Record, Resident #127 had a medical history that included a diagnosis of schizoaffective disorder. A hospital Discharge Summary, for a date of service of 09/11/2024, revealed Resident #127 was discharged from the hospital on [DATE] with discharge diagnoses that included schizoaffective disorder and schizophrenia. The Discharge Summary also reflected the resident was discharged from the hospital with orders for risperidone (an antipsychotic medication) for psychotic symptoms. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/17/2024, revealed Resident #127 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. According to the MDS, the resident had an active diagnosis of schizophrenia and received an antipsychotic medication during the assessment look-back period. Resident #127's Preadmission Screening and Resident Review (PASRR) Level I Screening, completed on 09/09/2024 at a local hospital, indicated the screening type was an Initial Preadmission Screening (PAS). The Level I screening indicated the resident did not have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance; however, a separate section of the screening that addressed psychotropic medications indicated the resident was receiving risperidone for schizoaffective disorder. The screening indicated the resident met the criteria for an Exempted Hospital Discharge, and the case was closed. A letter from the California Department of Health Care Services, dated 09/09/2024, revealed Resident #127's Level I screening was negative, and a Level II evaluation was not required. The letter also indicated the reason was due to an Exempted Hospital Discharge. The letter directed the facility to submit a new Level I screening on the 31st day if the resident remained in the facility greater than 30 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555068 If continuation sheet Page 3 of 5 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 11/21/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #127's medical record revealed no documented evidence the facility submitted a new Level I screening for Resident #127 due to inaccurate information on their initial Level I screening or when the resident remained in the facility greater than 30 days. During an interview on 11/21/2024 at 11:29 AM, Admissions Director #4 stated the hospital completed PASRRs prior to each resident's admission to the facility. Admissions Director #4 said medical records staff would notify them if any information in the PASRR was incorrect. During an interview on 11/21/2024 at 12:43 PM, the Medical Records Director stated residents who were admitted from the hospital brought their PASRRs with them, and if they did not, someone from the Medical Records Department would notify the Admissions Department, so they could reach out to the hospital for it. The Medical Records Director said medical records staff audited all admission paperwork, including PASRRs, for accuracy, but the MDS Department was responsible for ensuring the PASRRs were accurate. During an interview on 11/21/2024 at 12:57 PM, MDS Registered Nurse (RN) #2 said MDS staff reviewed the PASRR when completing the admission MDS to ensure it was accurate. MDS RN #2 confirmed a new Level I screening should have been completed for Resident #127. During an interview on 11/21/2024 at 2:00 PM, the Director of Nursing (DON) stated he expected MDS staff to ensure PASRRs were accurate. During an interview on 11/21/2024 at 2:20 PM, the Administrator stated he expected MDS and medical records staff to ensure PASRRs were accurate. 2. An admission Record indicated the facility originally admitted Resident #25 on 05/29/2015 and most recently admitted the resident on 05/08/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, major depressive disorder, bipolar disorder, anxiety disorder, and borderline personality disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2024, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses of anxiety disorder, depression, bipolar disorder, schizophrenia, post-traumatic stress disorder (PTSD), and borderline personality disorder and received antipsychotic medications during the assessment look-back period. Resident #25's care plan included a focus area, initiated on 05/10/2024, that indicated the resident was at risk for altered mood related to their overall health status, including diagnoses of schizophrenia, PTSD, bipolar disorder, borderline personality disorder, and severe rheumatoid arthritis. Another focus area, initiated on 05/10/2024, indicated the resident required the antipsychotic medications Abilify and perphenazine related to bipolar disorder and schizophrenia as evidenced by visual hallucinations and extreme mood swings. Resident #25's Preadmission Screening and Resident Review (PASRR) Level I Screening, completed on 05/07/2024 at a local hospital, indicated the screening type was an Initial Preadmission Screening (PAS). The Level I screening indicated the resident did have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance. The screening specified that the resident had a diagnosis of schizophrenia; however, the resident's other diagnosed mental illnesses were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555068 If continuation sheet Page 4 of 5 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 11/21/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not reflected. The screening indicated the resident met the criteria for an Exempted Hospital Discharge, and the case was closed. A letter from the State of California - Health and Human Services Agency California Department of Health Care Services, dated 05/07/2024, revealed Resident #25's Level I screening was negative, and a Level II evaluation was not required. The letter also indicated the reason was due to an Exempted Hospital Discharge. The letter directed the facility to submit a new Level I screening on the 31st day if the resident remained in the facility greater than 30 days. Resident #25's medical record revealed no documented evidence the facility submitted a new Level I screening for Resident #25 due to inaccurate information on their initial Level I screening or when the resident remained in the facility greater than 30 days. During an interview on 11/21/2024 at 12:54 PM, MDS Licensed Vocational Nurse (LVN) #3 stated she did not know PASRRs had an option for exempted hospital discharges. MDS LVN #3 said the facility should have submitted a new Level I screening for Resident #25. During an interview on 11/21/2024 at 1:59 PM, the Director of Nursing (DON) stated the facility should have submitted a new Level I screening for Resident #25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555068 If continuation sheet Page 5 of 5