F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide services in accordance with professional standards
of practice for one of two sampled residents (Resident 1) when license nurses did not accurately complete
Resident 1's elopement and wandering risk assessment. This failure had the potential to compromise the
facility's ability to provide resident-centered interventions based on assessment data.
Residents Affected - Few
Findings:
Review of Resident 1's medical record indicated she was admitted on [DATE] and re-admitted on [DATE]
with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to
abnormal brain development), chromosomal abnormality (a genetic condition that occurs when there are
missing, extra, or irregular portions of chromosomal DNA [a molecule that carried genetic instructions for
the development and functioning of all living organisms]), other lack of expected normal physiological
development in childhood (known as developmental delay, means a child or adult is not achieving the
expected developmental milestones at the typical age).
Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/21/25, indicated she had a
brief interview of mental status (BIMS, a structured cognitive test) scoring 3 (severe cognitive impairment).
Review of Resident 1's health status note, dated 1/28/25 at 00:23 a.m., indicated the resident eloped from
the facility during shift change, and the resident attempted to leave the facility to go home.
Review of Resident 1's elopement and wandering risk observation/assessment, dated 11/9/24, indicated: 0.
None present was marked for C. Disease diagnosis: does the resident have a diagnosis that may impact
cognition? (i.e., Alzheimer's disease, Anxiety disorder, Bipolar disorder, Delusions, Dementia, Depression,
ID/DD, OBS, Schizophrenia, or other not listed); H. Other relevant information was blank; I. Interventions: 1.
Has the care plan been initiated/updated to reflect interventions aimed at reducing the risk of unsafe
wandering or an elopement? was blank.
Review of Resident 1's care plans indicated there was no care plan developed for elopement or wandering.
During an interview and record review with assistant director of nursing (ADON) A on 4/7/25 at 9:10 a.m.,
she confirmed the record review. ADON A stated Resident 1's elopement and wandering risk
observation/assessment, dated 11/9/24 was not accurate for the resident's diagnoses. ADON A
acknowledged that 4. Two or more are present should have been marked for question C, and all sections
should
(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
05/15/2025
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 0658
have been completed.
Level of Harm - Minimal harm
or potential for actual harm
During an interview and record review with licensed vocational nurse (LVN) B on 4/7/25 at 3:45 p.m., she
confirmed she completed Resident 1's elopement assessment dated [DATE]. LVN B stated Resident 1's
elopement and wandering risk observation/assessment, dated 11/9/24 was not accurate for the resident's
diagnoses. LVN B acknowledged that 4. Two or more are present should have been marked for question C,
and all sections should have been completed.
Residents Affected - Few
Review of the facility's undated policy and procedure titled Wandering and Elopements indicated, The
facility will identify residents who are at risk of unsafe wandering and strive to prevent harm .If identified as
at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and
interventions to maintain the resident's safety.
Review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, dated
2001, indicated, A comprehensive, person-centered care plan that includes measurable objectives and
timetables to meet the resident's physical, psychosocial and functional needs is developed and
implemented for each resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555068
If continuation sheet
Page 2 of 2
