Health inspection·April 24, 2025

F 0607 2 filed a grievance that CNA 1 did not answer the call light for over an hour. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/24/25 at 1:37 p.m. Resident 3 stated CNA 1 had a Non-caring attitude. Residents Affected - Few During an interview on 4/24/25 at 2:48 p.m. with CNA 2, CNA 2 stated CNA 1 had a bad attitude, bossy, and did not answer residents' call lights. CNA 2 stated CNA 1 seemed like he did not see or hear call lights going off. During a concurrent interview and review of CNA 1's employment files on 4/24/25 at 12:27 p.m. with DSD, CNA 1's employment application listed a former employer and three individuals as references. DSD stated Human Resources (HR) did not require reference checks for prospective employees. DSD stated it was the facility's HR that conduct screening for prospective employees, and that while background screening was done, reference checks were not completed because they were not required anymore. During an interview on 4/24/25 at 12:40 p.m. with Assistant Executive Director (AED), AED stated reference checks were still required and should be done by DSD. AED stated, if reference checks were not done, the facility would not know the prospective employee's past performance and conduct with previous employer. During a review of the facility's policy and procedure (P&P) titled Policy Interpretation and Implementation, last revised 9/20/22, the P&P indicated, under Seven Components of Abuse Prevention Policy & Procedure, all potential employees are screened for a history of abuse, neglect, exploitation, mistreatment of residents. This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 2 of 4 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 04/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, for two of three sampled residents (Resident 1 and Resident 2), the facility failed to ensure allegations of abuse or mistreatment were reported to officials that included the State Survey Agency, Office of the Long-Term Care Ombudsman, and law enforcement officials within the required time frame. This failure had the potential to result in a lack of protection for residents alleging abuse or mistreatment. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in April 2023 with diagnoses that included anxiety disorder (a group of mental health conditions characterized by excessive and persistent fear or worry that interferes with daily life) and a need for assistance with personal care. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in January 2025 with diagnoses that included dependence on renal dialysis (a life-sustaining treatment used when kidneys are unable to properly filter waste and excess fluid from the blood), and muscle weakness. During an interview on 4/24/25 at 11:43 a.m. with Director of Staff Development (DSD), DSD stated, on 4/7/25, during the resident council meeting, Resident 1 reported CNA 1 was rough and aggressive during perineal care (the area of the body between the anus and the vulva in females and between the anus and the scrotum in males). DSD stated, on 4/11/25, four days after Resident 1 reported the incident, DSD interviewed CNA 1 about the alleged incident and CNA 1 was given verbal coaching (a form of coaching that involves speaking with an employee about their performance or conduct, often used for minor issues or concerns). DSD stated she had to wait until CNA 1 was scheduled to work on 4/11/25 to conduct the interview about Resident 1's allegation. DSD stated CNA 1 was then allowed to work and was back on schedule on 4/11/25 and 4/13/25. DSD stated, on 4/14/25, Resident 2 filed a grievance alleging CNA 1 pointed a finger at Resident 2 and said, You're not the only patient here! after Resident 2 got upset that CNA 1 took a long time to answer the call light. DSD stated the alleged incident happened on the evening shift on 4/13/25. DSD stated interviewing CNA 1 on 4/16/25, two days after the allegation, because CNA 1 was not scheduled to work until that day. DSD stated both incidents were reported to the State Survey Agency, Long-Term Care Ombudsman and local law enforcement officials on 4/16/25. During a telephone interview on 5/5/25 at 2:29 p.m., Registered Nurse (RN) 1 stated, in the evening shift on 4/13/25, Resident 2 was upset about waiting too long for CNA 1 to answer the call light. RN 1 stated he did not know CNA 1 was on a meal break and sent CNA 3 to change Resident 2 after a bowel movement. During a telephone interview on 5/5/25 at 2:36 p.m. with CNA 3, CNA 3 stated she was responding to Resident 2's call light that had been on. CNA 3 stated Resident 2 was upset that CNA 1 did not answer the call light and wanted to be changed after a bowel movement. During a review of Resident 2's Administration Note (AN), dated 4/13/25, the AN indicated imodium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 3 of 4 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 04/24/2025 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 0609 A-D oral solution (anti-diarrheal medication) was administered because Resident 2 was having diarrhea. Level of Harm - Minimal harm or potential for actual harm During a follow-up interview on 4/24/25 at 12:47 p.m. with DSD, DSD stated, although she received Resident 2's grievance on 4/14/25, DSD stated she wanted to talk to CNA 1 first before the allegation was reported to the appropriate agencies. DSD stated she should have reported the allegation right away. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled Elder and Dependent Adult Suspected Abuse & Reporting, last revised 9/20/22, the P&P indicated, under Reporting Requirements, the facility must Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made .Have evidence that all alleged violations are thoroughly investigated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555189 If continuation sheet Page 4 of 4