Health inspection·June 9, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm smoke got into the facility when the door to smoking area was left open. LVN 1 stated, the smoke in the hallway put residents at risk for breathing secondhand smoke, which was not healthy and worse than smoking. LVN 1 stated, the patio was the designated smoking area and although there was no doorbell, the door was supposed to stay closed until the residents were finished smoking. LVN 1 stated, there was no smoking allowed inside the facility so the smoke should not come into the building. Residents Affected - Some During a review of the facility's Policy and Procedure (P&P) titled, Smoking Policy - Residents, revised July 2017, the P&P indicated, smoking is only permitted in designated resident smoking areas, which are located outside of the building .smoking is not allowed inside the facility under any circumstances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 2 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 ensure two of three sampled residents (Resident 20 and Resident 47) received a Quarterly Minimum Data Set (MDS- an assessment used to track resident's status to plan care in between comprehensive assessments to ensure indicators of gradual changes are monitored) assessment. Residents Affected - Some This failure resulted in Resident 20 and Resident 47 to not receive an assessment for over three months and placed them at risk for unidentified changes in health status. Findings: During a review of Resident 20's undated admission Record, showed Resident 20 was admitted to the facility on [DATE]. During a concurrent interview and record review with Minimum Data Set Coordinator (MDSC 1), on 6/7/23, at 9:51 a.m., Resident 20's MDS assessments were reviewed in Electronic Health Record (EHR). MDSC 1 stated Resident 20's MDS assessment was not completed since 1/2023. MDSC 1 stated, she was responsible for completing the MDS assessments. MDSC 1 stated, she had started working on Resident 20's quarterly assessment dated [DATE], however it was not completely done until that day. MDSC 1 stated assessments should be completed within 14 days from the date of assessment. During a review of Resident 47's undated admission Record, indicated Resident 47 was admitted to the facility on [DATE]. During a concurrent interview and record review with MDSC 1, on 6/7/23, at 9:55 a.m., Resident 47's MDS assessments were reviewed in EHR. MDSC 1 stated Resident 47's quarterly MDS assessment dated [DATE] was not completed. MDSC 1 stated all residents should be assessed on a quarterly basis. During an interview on 6/7/23, at 9:58 a.m., MDSC 1 stated missing Resident 20 and 47's quarterly MDS assessments placed them at risk for missing the changes and decline in their health status. During a review of facility's undated Policy titled MDS 3.0 completion, the policy showed, 2.e. Quarterly Assessment- completed using an ARD [assessment reference date] no>92 days from the most recent prior quarterly or comprehensive assessments .7. a. All assessments shall be transmitted to the designated CMS system .within 14 days of completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 3 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 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 observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 365) assessed and treated for 2+ pitting edema (swollen part of the body due to excess watery fluid that gets a dimple or a pit up to four millimeters when it's pressed for a few seconds) on both lower extremities for a period of seven days. Residents Affected - Few This failure had the potential for Resident 365's both legs edema to get worsened and to suffer from related complications such as Fluid Overload (a medical condition with excessive accumulation of fluids in body's tissues and organs), Heart Failure (HF- when the heart is unable to pump blood efficiently), Deep Vein Thrombosis (DVT- a blood clot that forms in one of the deep veins in the body, usually in the legs). Findings: During a review of Resident 365's undated Profile Face Sheet the record indicated Resident 365 admitted to the facility on [DATE]. During a review of Resident 365's SNF admission History and Physical (H&P) dated 5/31/23, the H&P indicated Resident 365 had Dementia (memory loss) and Right leg fracture. During an observation on 6/4/23, at 8:59 a.m., Resident 365 was sitting in a wheelchair in her room. Resident 365's both lower extremities were swollen and had skin colored sheer stockings on. During a follow up observation on 6/7/23, at 8:46 a.m., Resident 365 still had swelling and had skin color sheer stockings on both lower legs. During a concurrent observation and interview on 6/7/23, at 11:30 a.m., with Licensed Vocational Nurse (LVN) 2 in Resident 365's room, while Resident 365 was sitting in a wheelchair, her legs were not elevated and had skin colored sheer stockings below the knees on both legs. LVN 2 stated, she was the regular charge nurse for Resident 365. LVN 2 assessed Resident 365's both lower extremities and stated Resident 365's left leg had 1+ edema (up to 2 mm pit) and right leg had 2+ edema (up to 4 mm pit). LVN 2 stated, she had been noticing edema on Resident 365's both legs since Resident 365's admission to the facility on 5/30/23. During a concurrent interview and record review on 6/7/23, at 11:55 a.m., with LVN 2, Resident 365's electronic health record including nursing progress notes, care plans, physician orders and interdisciplinary notes from 5/30/23 till 6/7/23 reviewed. LVN 2 stated, even though Resident 365 had edema on both legs since admission, she was unable to find documentation for an assessment, care plan, treatment orders, notification to physician and/ responsible party of Resident 365's edema on both legs. LVN 2 stated, untreated edema placed Resident 365 at risk for worsening of both legs edema. During an interview on 6/7/23, at 12:12 p.m., with the Director of Nursing (DON), the DON stated, an unassessed and untreated edema placed Resident 365 at risk for edema related complications including Fluid Overload, Heart Failure and Deep Vein Thrombosis. The DON stated he expected the licensed nurses to assess residents, notify the physician and responsible party of any changes in health condition of their assigned residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 4 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's Policy and Procedures (P&P) titled, Change in a Resident's Condition or Status dated 2021, the P&P showed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in resident's physical/emotional/mental condition. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Event ID: Facility ID: 555189 If continuation sheet Page 5 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to maintain safe water temperature for facility residents when hot water temperature from faucets in 31 of 31 bathrooms in resident rooms, and one of one resident shower room measured between 134 to 151.5 degrees Fahrenheit (°F). The facility had 26 of 56 residents (Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365) who were mobile and able to access bathroom faucets. Facility's residents and direct care staff were unaware of water boiler (a tank that heats water) malfunction and unsafe water temperature, even after identifying the issue, for three days. This failure placed Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365 at risk for burns (injury to skin or other tissue caused by heat) up to and including third degree burns (when all three layers of skin are burned) within two (2) seconds of contact with hot water at 148°F. Through observations, interviews, and record reviews, the facility showed they initiated the plan of action by turning the hot water heater (a tank that holds and heats water) thermostat down to 120°F; posted signage on every bathroom door warning of the hot water temperature; instituted checks every 30 minutes for Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365 identified as mobile and being able to access a faucet; trained staff regarding safety of water temperatures to prevent scalding residents; and performed temperature checks every two hours on all faucets accessible to residents until water temperature was 120°F or below. Findings: During a concurrent observation and interview on 6/05/23, at 12:10 p.m., in the hallway outside Resident 53's room, Resident 53 stated, his bathroom didn't have soap in the soap dispenser. State Agency Surveyor (Surveyor 1) tested the soap dispenser in the shared bathroom of Resident 53 and 38 (Bathroom A) and found it to be working when soap dispensed onto Surveyor 1's left hand. Surveyor 1 turned the hot water faucet on and immediately placed left hand into the water stream. The water was immediately (within 1-2 seconds) too hot to keep Surveyor 1's hand in the water stream to rinse the soap. Surveyor 1 observed left hand palm to be stinging and red. Surveyor 1 turned on cold water and rinsed the soap off the left hand. Surveyor 1 requested maintenance come to Bathroom A to evaluate hot water temperature at 12:15 p.m. During a concurrent observation and interview on 6/05/23, at 12:55 p.m., with Environmental Services Supervisor (EVS) 1, in Bathroom A, EVS 1 put his hand under the running hot water and stated it got too hot too fast. EVS 1 called for a thermometer to test the water temperature. During a concurrent observation and interview on 6/05/23, at 1:02 p.m., with EVS 1 and FS1 in Bathroom A, FS1 tested the hot water temperature. FS1 stated, the hot water temperature was 151.5°F. FS1 then went to the room next door and tested the hot water temperature of Resident 58's bathroom (Bathroom B) faucet. FS1 stated Bathroom B's hot water temperature was 150.1°F. FS1 stated hot water temperature should be maintained at and no more than 120°F in facility residents' rooms. FS1 also stated the boilers were old and needed to be replaced. FS1 stated the hot water temperature would be the same in 31 of 31 bathrooms in resident rooms because the same water line fed all rooms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 6 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0689 assigned to 56 residents residing at the facility. Level of Harm - Actual harm During a concurrent observation and interview on 6/05/23, at 1:12 p.m., with Certified Nurse Assistant (CNA) 5, in the shower room, CNA 5 put her hand under the hot water and stated, the hot water felt very hot. CNA 5 stated, staff had to mix hot and cold water in the shower to ensure the water temperature was okay before she gave showers to residents. Residents Affected - Few During a concurrent observation and interview on 6/05/23, at 2:00 p.m., with facility's vendor technician for environmental services, Service Technician (ST) 1, facility's water boilers were observed. ST1 stated, the temperature for the water heater that supplied water to resident rooms and shower room was 150°F while water heater thermostat was set to 160°F at that time. ST1 stated, he turned the thermostat down to 140°F and that should decrease water temperature of 1-2°F every hour. ST1 also stated he was at the facility also on 6/03/23 and 6/04/23 to make repairs because facility did not have supply for hot water. During a concurrent observation and interview on 6/05/23, at 2:10 p.m., with ST1, in Resident 41's bathroom faucet (Bathroom C), and resident Shower room, ST1 tested the hot water temperature. ST1 stated the hot water temperature was 134.2°F in Bathroom C and 141°F in resident shower room. During an interview on 6/05/23, at 2:10 p.m., Resident 53 stated there was no hot water on 6/3/23 and had to take a cold shower on 6/04/23. Resident 53 stated on 6/5/23, the water had been so hot that had to pull his hand out of the water stream quickly. Resident 53 stated he was not able to use hot water to wash his hands that day. During a concurrent observation and interview on 6/05/23, at 3:00 p.m., with EVS 1, in the basement boiler room, the water heater temperature was 159°F at that time. During a concurrent interview and record review, on 6/05/23, at 5:10 p.m., with ADM, Resident Census and Condition of Residents dated 6/05/23, and facility's untitled document with list of residents who were to ambulate with/without assistive devices were reviewed. ADM stated facility had a total of 26 residents who had access to sinks because they moved independently or with assistive devices. The ADM stated Residents 47 and 53 ambulated independently without assistive devices; Residents 3, 36, 38, 50, and 365 ambulated with assistive devices; and Residents 1, 2, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 37, 42, 43, 52, 58, 313 were able to self-propel in a wheelchair. During an interview on 6/09/23, at 9:40 a.m., the ADM stated she expected all outside vendors were escorted by facility's designated staff and vendors should not work without direct observation in the facility. The ADM stated she was unaware of water temperature issues for 6/3/23 till 6/5/23 until Surveyor 1 brought it to facility's attention. During a concurrent interview and record review on 6/09/23, at 10:04 a.m., with FS1, Logbook Report, dated 6/05/23 was reviewed. FS1 stated, facility had two hallways designated to resident rooms, and he completed the water temperature checks on a weekly basis. FS1 stated weekly water temperature checks were due on 6/3/23; however, he did not complete it until 6/5/23. The Report showed FS1 documented the hot water temperature was 150°F for resident rooms and 145°F for the shower room on 6/05/23. FS1 stated, he checked the resident rooms only at the end of both halls. FS1 stated, on 6/3/23, one of his coworkers, Maintenance Technician (MT) 1 told him that the water boiler was leaking and at noon he called the vendor company that they used for maintenance of facility's environmental services and left a voice message. FS1 stated, he did not tell anyone, including facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 7 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0689 administration, that he turned the boiler off and/or to check water temperatures to ensure safe water temperature for residents at the facility. Level of Harm - Actual harm Residents Affected - Few During a concurrent observation and interview on 6/09/23, at 10:45 a.m., with FS1, in the boiler room, two large boiler units were positioned near center of one wall. FS1 pointed to a blue box on each unit and stated they must be the thermostat for the boilers. During a concurrent observation and interview on 6/09/23, at 10:52 a.m., with Executive Director (ED) and FS1, in the boiler room, ED stated the boilers constantly alternated to prevent wear on a single boiler so neither boiler is designated as back up. ED then pointed to the thermostat on the water heater opposite the boilers and stated the thermostat was replaced after the water temperature issue was identified on 6/5/23. During a review of Centers for Medicare and Medicaid Services State Operations Manual (SOM) Appendix PP, revised 2/03/23, the SOM indicated many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding (a burn resulting from heated fluids). SOM Table 1 indicated safe bathing temperature was 100°F. The SOM also indicated two (2) seconds was the time required for a third degree burn at 148°F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 8 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, monitor, and intervene for weight loss of seven (7) pounds (lbs.), 5.6% in one month, for one of two sampled resident (Resident 8) for more than one month. Residents Affected - Few This failure resulted in Resident 8 to not receive an assessment and intervention to prevent further weight loss for one month and Resident 8 lost 1.8 more lbs. during that period. Resident 8 had a severe weight loss of 13.4 lbs. with a percentage of 10.31% within a period of three (3) months. Resident 8 was at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition, and decline in functional status. Findings: During a review of Resident 8's Profile face sheet, Resident 8 was recently readmitted on [DATE] with diagnosis of Epilepsy (seizures), Dysphagia (difficulty or discomfort in swallowing food or liquids), and Major Depressive Disorder (characterized by persistent feelings of sadness, hopelessness and worthlessness). During a review of Resident 8's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/14/23 indicated Resident 8's Brief Interview for Mental Status (BIMS- a mental status exam) was three (3) out of 15, indicating severely impaired mental status. The MDS assessment also indicated Resident 8 required one staff's extensive assist with eating. During observation on 6/6/23, at 12:51 p.m., with Certified Nursing Assistant (CNA) 2, in Resident 8's room, CNA 2 was feeding Resident 8 at her bedside. During an interview on 6/6/23, at 1:45 p.m., CNA 2 stated Resident 8 consumed 50% of her lunch. CNA 2 also stated Resident 8 ate 25% of breakfast that morning. During a concurrent interview and record review on 6/7/23, at 3:09 p.m., with Registered Dietician (RD) 1, Resident 8's electronic medical record for Resident Vital Stats was reviewed. The record showed Resident 8's weight on 4/3/23 and 5/7/23 was 125.4 lbs. and 118.4 lbs. respectively. RD 1 stated, Resident 8 lost a total of eight (8) lbs./5.6% in one month, which was a significant weight loss. RD 1 stated, she was not aware of Resident 8's significant weight loss as she only utilized a Weight Binder to track residents' weights. During a concurrent interview and record review on 6/7/23, at 3:15 p.m. with RD 1, at the nursing station, a Weight Binder with a document labeled Monthly Weight Grid-June 2022 through May 2023 was reviewed. The document indicated Resident 8's weight was not entered for the month of 5/2023 and 6/2023. RD 1 stated, Resident 8 could have been on weekly weight monitoring and a fortified diet (more nutrients added to the diet) with additional 600 calories to ensure no more further weight loss specially because Resident 8 had a history of weight fluctuations; however it was not done since 5/7/23. RD 1 also stated Resident 8's physician and the responsible party should have been made aware of Resident 8's significant loss. During a concurrent interview and record review on 6/7/23, at 3:20 p.m., Resident 8's Quarterly Nutritional Assessment dated 5/22/23 was reviewed. The assessment indicated Noted weight loss this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 9 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0692 Level of Harm - Actual harm Residents Affected - Few month, recommended to reweigh, Goal to maintain 118 pounds. RD 1 stated however she did not recall if she asked Restorative Nursing Aide (RNA- staff responsible to weigh residents) to reweigh Resident 8 on or after 5/22/23. During a concurrent a record review on 6/8/23, at 10:15 a.m., with RD 1, Resident 8's electronic health record for weights was reviewed. The record indicated Resident 8 weighed 116 lbs. on 6/7/23, indicating Resident 8 lost 1.8 lbs. since 5/7/23. During an interview 6/08/23, at 2:03 p.m., RD 1 stated, Resident 8 was expected to stay in weight range of 120-130 lbs., it was alarming if it went down below 120 as she was not on a physician prescribed weight loss regimen. During a concurrent interview and record review on 6/8/23, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 8's electronic medical record including progress notes, weights, weekly summary from 5/1/2023 till 6/8/2023 reviewed. LVN 2 stated Resident 8 was more sleepy last week, and is eating more in her room as compared to before. LVN 2 stated, she notified Resident 8's physician about her increased sleepiness and decreased meal intake couple days ago but was unable to find any documentation regarding her communication and interventions. Resident 8's Licensed Nurse Weekly Summary dated 5/3/23 under Nutrition, showed stable weight, increasing weight and decreased weight on 5/10/23, 5/18/23, and 5/24/23 respectively while Resident 8 was being weighed only on a monthly basis. During an interview on 6/9/23, at 10:44 a.m., with Director of Nursing (DON), DON stated unaddressed weight loss for Resident 8 placed her at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition, and decline in functional status. During a concurrent interview and record review on 6/9/23, at 11:15 a.m., with RD 1, the facility's Policy and Procedure(P&P) titled Fortification of Food: Increasing Calories and/or Protein in the Diet, dated 2018, was reviewed. The P&P indicated, The enrichment of foods will be done on an individual basis for the residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. RD 1 stated facility used ½ a ladle scoop of margarine in two food items to meet the extra 600 calories per day for fortification of resident's meals. RD 1 stated each ½ ladle of margarine provided extra 300 calories. During a review of the facility's Policy and Procedures (P&P) titled, RDs For Health Care, INC. Weight Change Protocol dated 2018, the P&P indicated, Early identification of weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. Residents will be weighed on a monthly basis and weekly for those newly admitted and those deemed to be at high risk for weight changes according to the facility's policies. Variances are calculated from monthly and weekly weights that are obtained by the facility staff. Residents who experience significant changes in weight or insidious weight loss will be assessed by RD. The following criteria define significant or insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights, pounds weight loss or gain in 1 week or as facility policy states, pounds weight loss or gain in 1 month, 5.0% weight loss or gain in 1 month, 7.5% weight loss or gain in 3 months, 10% weight loss or gain in 6 months. During a review of facility's Policy and Procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated 2017, the P&P showed, The nursing staff will monitor and document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 10 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0692 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with weight loss or gain, anorexia and significant risk for impaired nutrition. The staff will report to the physician significant weight losses or gains or any abrupt or persistent change from baseline appetite or food intake. Event ID: Facility ID: 555189 If continuation sheet Page 11 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store all medications for one of 21 sampled residents (Resident 56). For resident 56, one lidocaine patch (a patch placed on the skin generally used to help relieve nerve pain), was found on the bedside table. This deficient practice did not ensure medication was kept secured and had potential for medication errors. Findings: During initial observation on 6/4/23, at 10:05 am, in room [ROOM NUMBER], there was a lidocaine patch 5% found on Resident 56's bedside table. During a concurrent interview on 6/4/23, at 10:15 am, Licensed Vocational Nurse (LVN) 2, LVN 2 stated, she did not know who put the lidocaine patch there and how long it has been there. LVN 2 stated, it happens to be there, it is unused but opened.LVN 2 stated, Resident 56 had an order for it once a day. LVN 2 stated it should not be at Resident's bedside and should be in the medication cart. She took it and stated she was going to destroy it. During an interview on 6/6/23 at 10:15 am, with Director of Nursing (DON), DON stated, the family put it there and he believed it had been there for 24 hours. DON stated, staff had been in the room to give medications or to care for Resident. DON stated, the danger of leaving the lidocaine patch at the bedside, it could result in someone taking it and swallowing it or putting it in the mouth. During an interview on 6/8/23 at 11:45 am, with DON, DON confirmed that Resident 56 was not appropriate for self administration and was not assessed for self administration. The facility's policy and procedure (P&P) titled, Storage of medications dated April 2019, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .only persons authorized to prepare and administer medication have access to locked medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 12 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and document review, the facility failed to store, prepare, and serve food in a safe and sanitary manner when: Residents Affected - Many 1. A blender was dirty 2. The chopper was not maintained in good condition. 3. Dry cereal was kept beyond use-by date. These failures had the potential to result in food-borne illnesses to 52 residents who receive food from the kitchen out of a facility census of 56 Findings: 1.During the initial tour of the kitchen on 6/4/23 at 8:15 am, with the Culinary Service Director (CSD), a blender on the countertop was observed with scattered food residue on the base and thick food residue inside the plastic container of the blender. In a concurrent interview with the CSD, the CSD stated, the blender should be clean. During an interview on 6/6/23, at 3 pm, with the Registered Dietician (RD), the RD stated it was a food safety issue and they should be cleaning equipment after each use. 2. During the initial tour of the kitchen on 6/4/23, at 8.17 am, with the CSD, the chopper had some food residue around the base area. The chopper had some white scratches around the base, and the silver part covering the buttons was peeling on the right side. During an interview with the RD on 6/6/23, at 3 pm, the RD stated, the peeling area could harbor bacteria and the sharp edge could also be harmful to staff. During a review of the facility's policy and procedure (P & P) titled, Sanitation, dated 2018, the P & P indicated, .all utensils, ., and equipment shall be kept clean, maintained in good repair and shall be free from . open ., cracks and chipped areas. 3.During the initial tour of the kitchen dry storage room, on 6/4/23, at 8:40 am, with the CSD, on the shelf were 32 packages of 4 oz servings of Kellogg's frosted flakes stored in a box with a use by date of 8/28/22. The CSD stated, dry cereal has 6-month shelf life. The CSD acknowledged they were beyond the use-by date and had to be discarded. During an interview on 6/6/23, at 2:25 pm, with RD, RD acknowledged this would be a concern and not okay, they should not have expired food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 13 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0812 The facility's P & P titled, Dry Goods Storage Guidelines, dated 2018, indicated, Cereals, ready to eat: Unopened on shelf- 6 months, Opened on shelf- 2 months. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 14 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to ensure a complete and accurate direct care staffing data was submitted to Centers of Medicare and Medicaid Services (CMS) for first quarter (10/2022 till 12/2022) of Federal Fiscal Year (FFY) 2023 (FFY starts on October 1st and ends on September 30th every year). This failure resulted in lack of reporting of facility's direct care staffing data as required by CMS. Findings: During a concurrent interview and record review, on 6/07/23, at 12:49 p.m., with Administrator (ADM), CASPER Report 1705D: FY Quarter 1 2023 (October 1 - December 31) dated 5/31/23, was reviewed. The CASPER Report (a staffing report used as an indicator of quality of care) showed the facility triggered for failing to submit data for Quarter 1 of FFY 2023. The ADM stated it was the administrator's responsibility to send Payroll Based Journal (PBJ - information about direct care staff, employee turnover, and census data) staffing quarterly. The ADM stated, facility should retain the staffing data submission validation report if the data was submitted for 10/2022- 12/2022 quarter. During a concurrent interview and record review on 6/7/23, at 12:55 p.m., with the ADM, a brown accordion folder was reviewed. The ADM stated, facility kept the data validation reports for staffing in that folder. The ADM stated, she was unable to locate the staffing data validation report for first quarter of Fiscal Year 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 15 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: 1. Residents Affected - Some Ensure staff performed hand hygiene when entering, exiting resident room, cleaned reusable blood pressure monitoring cuff in-between residents for three (Resident 46, Resident 314, and Resident 18) out of 21 sampled residents. 2. Ensure licensed staff performed hand hygiene when administering medications to resident 31 via G-tube (a tube inserted through the walls of the abdomen into the stomach to give medicine, fluids, and food) after touching resident and resident surroundings 3. Ensure nebulizer (a machine that turns liquid medication into a mist to be inhaled) tubing was dated and labeled for Resident 46 These failures had the potential to result in: Spreading infection which could result in hospitalization. Findings: 1. During an observation on 06/04/23 at 8:35 a.m., Certified Nursing Assistant (CNA 1) was observed checking the blood pressure for resident 314, then using the same blood pressure cuff to check the blood pressure for resident 18. CNA 1 was then observed exiting Resident 314 and Resident 18's room without performing hand hygiene and walking into resident 46's room without performing hand hygiene. CNA 1 took Resident 46's blood pressure without cleaning the blood pressure cuff. CNA 1 was then observed exiting Resident 46's room without performing hand hygiene, using the charting station in the hallway, then entering Resident 314 ad Resident 18's room without performing hand hygiene. During an interview on 06/04/23 at 8:51 a.m., with CNA 1, CNA 1 stated she usually take care of residents 46, 314, and 18 during the morning shift. CNA 1 stated, she forgot to perform hand hygiene when going from room to room did not sanitize the blood pressure cuff after each resident. CNA 1 also stated, that if there is no sanitization between residents, there is a possibility of spreading infection. During an interview on 06/06/23 at 2:22 p.m., with Director of Nursing (DON), DON stated the expectation for hand hygiene is to gel in, gel out between rooms and for reusable equipment, such as blood pressure cuffs, is to clean after every use; each vital signs machine has a sign which states Clean after every use. DON stated that the consequences of no hand hygiene or cleaning reusable equipment could lead to hospital acquired infections, outbreaks, or transmission of infections such as norovirus (a virus that causes food poisoning), c. diff (a bacteria that causes severe diarrhea), or VRE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 16 of 17 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 555189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601 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 (vancomycin-resistant enterococci; bacteria that cannot be killed with strong antibiotic). Level of Harm - Minimal harm or potential for actual harm During a review of facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Equipment, dated 2022, policy and procedure indicated, .'Reusable multiple-resident items' are items that maybe used multiple times for multiple residents. Examples include .blood pressure cuffs . and 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include .d. Multiple-resident use equipment shall be cleaned and disinfected after each use. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 17 of 17