Health inspection·August 26, 2025

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 accuracy, truthfulness, and completeness of information for the facility census of 51, including two of two sampled residents (Resident 1 and Resident 2) when the facility provided false and misleading information regarding Resident 2's room placement, which prevented the timely readmission of Resident 1 from the hospital.This failure resulted in lack of transparency and inconsistencies between the facility's census record and actual resident placement and reported information to surveyors. These discrepancies had the potential to compromise Resident 2's safety, delay the provision of necessary care and service, and cause a delay in Resident 1's prompt return to the facility.During a record review of Resident 1's admission Record (AR), printed on 8/22/25, the AR indicated Resident 1 was admitted to the facility in July 2025 with diagnosis of acute and chronic respiratory failure (occurs when there is not enough oxygen in the blood). During a record review of Resident 1's record, titled, Leaving Facility Against Medical Advice (AMA), dated 8/21/25, the AMA form indicated, Resident 1 refused to sign the AMA form and Resident 1 was insisting to be transferred to the hospital. During a record review of the facility's census, dated 8/22/25, two different versions of the facility's census were reviewed: 8/22/25 - Received upon entrance at 11:25 a.m., the census listed room [ROOM NUMBER] and room [ROOM NUMBER] as empty and no assigned residents, while Resident 2 was listed in room [ROOM NUMBER]. 8/22/25 - Received via email at 4:13 p.m., the census indicated Resident 2 was moved from room [ROOM NUMBER] to room [ROOM NUMBER], while room [ROOM NUMBER] remained unassigned. During a phone interview on 8/22/25 at 3:28 p.m. with the hospital's Case Manager (CM), CM stated the facility was refusing to readmit Resident 1 due to no available isolation rooms. During a phone interview on 8/22/25 at 3:54 p.m. with the Administrator, the ADM stated they were not able to accommodate Resident 1 back to the facility because there were no empty rooms available that can be used as an isolation room. The ADM further stated room [ROOM NUMBER] was already assigned to a new admission, making it unavailable for Resident 1's readmission. During a follow-up concurrent record review and phone interview on 8/22/25 at 4:13 p.m. with the ADM, two different copies of facility's census dated 8/22/25 were compared and reviewed. The ADM stated Resident 2 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] because Resident 2's roommate was agitated, and the room change was made to prevent further issues or altercations. Contrary to the ADM's earlier statement that a new admission was placed in room [ROOM NUMBER]. The ADM further stated there were still no available rooms to readmit Resident 1 from the hospital. During a record review of the facility's census, dated 8/23/25 through 8/26/25, the facility's census indicated the following:8/23/25 - Resident 2 was incorrectly listed in room [ROOM NUMBER]; room [ROOM NUMBER] was unassigned.8/24/25 - Resident 2 was incorrectly listed in room [ROOM NUMBER]; room [ROOM NUMBER] was unassigned.8/25/25 and 8/26/25 - Resident 2 was incorrectly listed in room [ROOM NUMBER]; room [ROOM NUMBER] was assigned to another resident who had not been admitted to the facility.During a Residents Affected - Few Page 1 of 2 555189 555189 08/26/2025 Mercy Retirement & Care Center 3431 Foothill Blvd. Oakland, CA 94601

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few record review of Resident 2's AR, printed on 8/26/25, the AR indicated Resident 2 was admitted to the facility in July 2025 with diagnoses of right femur fracture (broken thigh bone), chronic pain, and osteoarthritis (degenerative joint disease).During an interview on 8/26/25 at 12:54 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 2 was very alert and oriented. CNA 1 stated Resident 2 had been in the same room since she was admitted and had not been moved to a different room. During an observation and interview on 8/26/25 at 12:56 p.m. with Resident 2 in room [ROOM NUMBER], Resident 2 was sitting in her bed, awake and alert. Resident 2 stated she had been admitted to the facility since July 2025. Resident 2 stated she had not been transferred to any other rooms. Resident 2 stated she had no issues with the current room and the roommate. Resident 2 further stated she and roommate get along well just fine. Resident 2 further stated there had been no incident of any sort of altercations between her roommate or any other residents. During a concurrent record review and interview on 8/26/25 at 1:30 p.m. with Medical Records Director (MDR), the facility's census dated 8/23/25 through 8/26/25 were reviewed. The MDR stated the Admissions Director (AD) was primarily responsible for updating and maintaining the facility's daily census records. During a concurrent record review and interview on 8/26/25 at 1:32 p.m. with AD, the facility's census dated 8/25/25 and 8/26/25 were reviewed. The AD stated she was not responsible for updating the facility's daily census records. AD stated she only updated the census when there were pending admissions. During a follow-up interview on 8/26/25 at 2:47 p.m. with CNA 1, CNA 1 confirmed Resident 2 did not have any altercations with Resident 2's roommate or any other residents. During an interview on 8/26/25 at 4:11 p.m. with the ADM, the ADM stated Resident 2 had asked the Social Worker for a room change. The ADM stated CNA 1 was instructed to move Resident 2 to room [ROOM NUMBER]; however, CNA 1 did not do the room change as directed. The ADM further stated she was not sure why Resident 2 wanted to change rooms. The ADM stated when room changes happen, the facility typically just moved the residents around without any supporting paperwork to document the transfer. The ADM stated the census records from 8/22/25 through 8/26/25 were not updated because neither the MRD nor AD knew that the room change for Resident 2 did not happen. The ADM stated it was an error, and the census should have been updated to reflect correct information.During a record review of the facility's document, titled, Facility Assessment, dated July 2025, the Facility Assessment indicated, The purpose of the Facility Assessment is to determine what resources are necessary to care for the residents completely during both day-to-day operations and emergencies.The Facility Assessment is organized in three parts: 1.Resident profile including numbers, diseases/conditions.factors that impact care.2. Services and care offered based on resident needs.3. Facility resources needed to provide competent care for residents.Sources of this assessment include, but are not limited to.Resident Census and Condition of Residents.and/or Roster/Sample Matrix form.and in-house designed reports. 555189 Page 2 of 2