Health inspection·May 15, 2025

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 Page 1 of 2 555068 555068 05/15/2025 White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128

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. 555068 Page 2 of 2