Mercy Retirement & Care Center
Inspection Findings
F-Tag F0835
F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
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MERCY RETIREMENT & CARE CENTER in OAKLAND, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OAKLAND, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MERCY RETIREMENT & CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.