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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555189 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 08/26/2025 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)