Health inspection·September 27, 2024

F 0684 finger and pinky finger on the left hand were inserted for the hand contractures. Level of Harm - Actual harm During an observation and interview on 9/27/24 at 1:58 p.m. with CNA 1, the finger contracture cushion/hand roll sample was Residents Affected - Few observed. CNA 1, at this time, stated she only placed the hand roll in the left hand of the Resident 1 to hold it and did not insert fingers in the loops of the cushion. CNA 1 stated somebody might have placed the left pinky finger in the small ring which should not be. During an interview and observation on 9/27/24 at 3:37 p.m., with CNA 2, CNA 2 stated she took care of Resident 1 in the evening shift (3 p.m. to 11 p.m.) on 9/9/24. CNA 2 stated on 9/9/24, around almost 10 p.m., she went to the Resident 1 ' s room and noticed something was wrong with Resident 1. CNA 2 stated she was about to give bed bath to Resident 1, but he resisted care at that time. CNA 2 stated she saw Resident 1's left hand pinky finger was inserted in one of the tight rings of hand roll causing purplish discoloration, and she went straight to Registered Nurse (RN) 1. CNA 2 stated she suggested RN 1 to cut the tight ring of the hand roll, because it was very tight. CNA 2 demonstrated the placement of the left pinky finger using the sample hand roll, and how the left pinky finger was inserted in the tight ring hole. CNA 2 stated her shift was from 3:00 p.m. to 11:15 p.m. but she did not pay attention and did not know Resident 1 was using the hand roll for his left hand the whole time. During an interview on 9/27/24 at 3:22 p.m. with RN 1, RN 1 stated during evening shift on 9/9/24, CNA 2 called her attention for Resident 1. RN 1 stated she saw Resident 1 ' s left pinky finger placed on the last ring of the hand roll and stated she was not sure if it was supposed to be there. RN 1 stated the left pinky finger was purplish in color and was bleeding. RN 1 stated Resident 1 was moaning at that time. RN 1 stated she rushed to get a scissor but was not sure how to cut it since Resident 1 ' s left pinky finger was tightly stuck in the ring of hand roll cushion. RN 1 demonstrated the placement of the left pinky finger using the sample hand roll, and the left pinky finger was placed all the way inside the tight ring. During an interview on 9/27/24 at 3:45 p.m., with RN 2, RN 2 stated he was Resident 1 ' s assigned charge nurse in evening shift (3 p.m. to 11:30 p.m.) on 9/9/24. RN 2 stated on 9/9/24 around 5:00 p.m., he saw Resident 1 lying in bed when he administered evening medications to him but did not remember seeing the Resident 1 ' s hands. RN 2 stated he did not know Resident 1 required a hand roll and had not seen him using one before. RN 2 stated he did not know who put on the hand roll in Resident 1 ' s left hand. RN 2 also stated somebody must have placed it on, since Resident 1 did not have the ability to do so. RN 2 stated he saw Resident 1 ' s left hand after RN 1 had already cut the hand roll cushion. RN 2 stated Resident 1 had a cut open wound about 1.0 cm. deep and, and it was bleeding. RN 2 stated the hand roll can be placed for a long period of time, but it depends. RN 2 stated hand rolls need to be taken off intermittently, otherwise they could impede the blood circulation in fingers. During a record review of Resident 1 ' s progress notes dated 9/9/24, documented by RN 1, the record indicated, Around 10:15p.m., [CNA 2] showed to [RN 1] [Resident 1 ' s] left pinky. [RN 1] assessed finger and finger was purple and noted to be wrapped with the ring part of a hand splint. [RN 1] cut the ring around the finger and the finger was almost falling off. Bone was visible. [RN 1] reported to on-call [Medical Doctor] and [Medical Doctor] gave an order to send out [Resident 1]. [RN 1] called 911 and ambulance came around 10:30 p.m. Ambulance left with [Resident 1] around 10:50 p.m. [RN 1] notified [Responsible Party] . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 2 of 3 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 09/27/2024 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a record review of Resident 1 ' s Acute Care Hospital record dated 9/10/24, the record indicated, [Skilled Nursing Facility] found left pinky open wound this [morning] (9/10). Occurred after [one] day of application of a cushion to his left hand to prevent him from scratching himself. Subsequently, [Skilled Nursing Facility] suspected that the cushion was wrapped around his finger too tight and dug into his skin. Per [Emergency Medical Services], the vitals (blood pressure, temperature, respiration, pulse, pain) at the scene noted. [Resident 1] to be febrile [increased body temperature] and mildly tachypneic [abnormally labored breathing] . The record also indicated Resident 1 had . hypotensive [low blood pressure] episodes .could [likely] be from acute open [left] 5th digit infection at wound site and that Resident 1 received Cefazolin 1 grams (an antibiotic medication to manage infection) . Event ID: Facility ID: 555189 If continuation sheet Page 3 of 3