Health inspection·June 10, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 reviews, the facility failed to provide the necessary care and services for two of 3 sampled residents (Residents 1 and 2) when: Residents Affected - Few 1.Facility staff did not ensure timely assessment, physician notification, or complete documentation of a change in condition for Resident 1; and 2. Facility staff did not notify the physician or conduct a thorough investigation after Resident 2 fell on 2/27/25. These failures placed Residents 1 and 2 at risk for delayed treatment and potential harm. Findings: 1. A review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease (partial or complete paralysis on one side of the body after a stroke or brain injury), traumatic hemorrhage of cerebrum (bleeding in the brain caused by trauma), type 2 DM (diabetes mellitus, a chronic condition that affects how the body processes blood sugar), memory deficit following cerebral infarction (memory problems after a stroke). A review of Resident 1's transfer form, dated 2/17/25 at 6:45 p.m., indicated Resident 1 was transferred to the hospital due to malaise (a general feeling of being unwell or weak). A review of Resident 1's progress note, completed by the evening (PM) shift Licensed Vocational Nurse (LVN) A on 2/17/25 at 11:23 p.m., indicated that Resident 1's wife transported him to the hospital after he stated he was not feeling well. LVN A documented that Resident 1's vital signs at the time were within normal limits: blood pressure (BP, the force of blood pushing against the walls of the arteries) 152/89, pulse 76, respiration 18 (process of breathing), and oxygen saturation 97% (O2 sat, the percentage of oxygen in the blood). The progress notes further stated that Resident 1 was taken by his wife at 6:15 p.m., and that at 10:30 p.m., the wife reported Resident 1 had been admitted to the hospital for sepsis (life-threathening condition that could arise due to body's reaction to an infection), as he had been in the past. LVN A documented that the AM (morning) supervisor was notified, and the NOC (night) shift nurse was informed that the resident was in the hospital. A review of the eINTERACT Change of Condition (COC) form, completed by the NOC shift nurse on 2/18/25 at 12:26 a.m., indicated that Resident 1's change in condition began in the afternoon of 2/17/25. The form stated that the resident was complaining of malaise, had vital signs within normal range, Page 1 of 3 555068 555068 06/10/2025 White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and no shortness of breath (SOB) or complaints of pain. The form also documented that Resident 1's blood glucose (BG, the level of sugar in the blood) on 2/17/25 at 4:20 p.m. was 328 mg/dL (milligrams per deciliter, unit of measurement). According to the COC form, the primary care clinician was not notified until 11:38 p.m., several hours after Resident 1 had already been taken to the hospital by his wife. Further review of Resident 1's clinical records, no other documentation indicating what ocurred prior or during the time when Resident 1 left the facility at 6:15 p.m. During an interview on 2/25/25 at 3:30 p.m., with the Certified Nursing Assistant (CNA) B assigned to Resident 1 on the evening of 2/17/25, CNA B stated the charge nurse told her Resident 1 was not feeling well and asked her to take his vital signs. CNA B stated the vital signs were within normal limits. Resident 1 told CNA B he was feeling tired. During an interview with the Director of Nursing (DON) on 2/25/25 at 4:15 p.m., the DON stated that when a resident or family requests a hospital transfer, staff should assess the resident, notify the physician of the assessments, and the family's request, and may facilitate the transfer per family's request, even if vitals signs appear stable. During an interview with the Nurse Supervisor (NS) C on 4/29/25 at 4 p.m., NS C stated she was not aware of Resident 1's complaint or the family's request for transfer until after Resident 1 had left the facility. The NS C confirmed that no timely assessment or documentation occurred during the PM shift, and that the facility protocol requires nurses to assess the resident, document changes, notify the physician, and respond to family requests appropriately. A review of Resident 1's hospital Discharge summary, dated [DATE], stated the resident was admitted on [DATE] for suspected sepsis related to a complicated urinary tract infection (UTI, bladder infection). The summary also noted that the resident had fever, chills, shaking, and malaise for several days prior to admission. The hospital suspected that a viral upper respiratory infection (URI, viral or bacterial illness in the upper airways, including the nose, sinuses and throat) triggered sepsis. Review of the undated facility's policy titled Change in a Resident's Condition or Status indicated, .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment, Recommendation) Communication form . 2a.A review of Resident 2's clinical record indicated the resident was admitted on [DATE] with diagnoses including Disseminated Coccidioidomycosis (a serious fungal infection that spread throughout the body); Unspecified injury of Thoracic Spinal Cord (an unclear injury to the part of the spinal cord located in the upper and middle back). A review of the COC form, dated 2/27/25, indicated NO under physician notification, and the explanation field was marked N/A. A review of Resident 2's Progress notes showed no documentation that the physician had been notified following the fall on 2/27/25. 555068 Page 2 of 3 555068 06/10/2025 White Blossom Care Center 1990 Fruitdale Avenue San Jose, CA 95128

F 0684 Level of Harm - Minimal harm or potential for actual harm During a phone interview with Registered Nurse (RN) D on 5/1/25 at 4:32 p.m., night shift RN D stated that Certified Nursing Assistant (CNA) E reported Resident 2 had fallen during activity of daily living care around midnight. RN D confirmed that he did not notify the physician and did not report to the morning shift nurse about not calling the physician. RN D acknowledged that he should have notified the physician about Resident 2's fall or endorsed it to the morning shift. Residents Affected - Few During a concurrent interview and record review with the DON on 5/20/25 at 4:35 p.m., the DON confirmed that the physician was not notified. The DON stated that the best practice was to notify the physician and document fall monitoring in the progress notes. 2b. A review of the Interdisciplinary team (IDT, a group of healthcare staff from different areas who work together to plan and provide care for a resident) note indicated the IDT note was created on 3/11/25 - 11 days after the effective date of 2/28/25. During a phone interview with CNA E on 5/20/25 at 8:23 a.m., CNA E stated he was assisting Resident 2's roommate at the time of the fall and did not witness the incident. CNA E reported hearing a loud noise and then found Resident 2 on the floor. During a concurrent interview and record review of the IDT note with the Assistant Director of Nursing (ADON) on 5/20/25, at 4:45 p.m., the ADON stated she conducted the fall investigation by interviewing Resident 2 and RN D but did not interview CNA E due to scheduling issues. ADON acknowledged that CNA E's statement contradicted the IDT note, which stated the fall occurred during activity of daily living care with CNA E present. Review of the undated facility's policy titled Change in a Resident's Condition or Status indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition .a. accident or incident involving the resident .d. significant change in the resident's physical/emotional mental condition .g. need to transfer the resident to a hospital/treatment center Review of the undated facility's policy titled Accidents and Incidents - Investigating and Reporting indicated, All accidents or incidents involving residents, employess, visitors, vendors, etc., ocurring on our premises shall be investigated .c. the circumstances surrounding the accident or incident m. other pertinent data as necessary or required 555068 Page 3 of 3