Mercy Retirement & Care Center
MERCY RETIREMENT & CARE CENTER in OAKLAND, CA — inspection on September 23, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observation, interview and record review, for one of four sampled residents (Resident 3), the facility failed to ensure services provided meet professional standards of care when scheduled medications were not administered in a timely manner.This failure had the potential to result in ineffective management of medical conditions.During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility in December 2023 with multiple diagnoses that included major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), depression, anxiety disorder (excessive worry, fear and nervousness), and essential hypertension (elevate blood pressure).
During an interview on 9/19/25 at 1:05 p.m. with Resident 3, Resident 3 stated having to beg for nurses for scheduled medications and that new nurses did not know which medications to administer and were inconsistent in administering them.During a concurrent observation and interview on 9/19/25 at 1:12 p.m. with Registered Nurse 1 (RN), RN 1 stated Resident 3, who was alert and oriented, walked independently in the hallway. RN 1 stood by the medication cart a few rooms away from Resident 3 and stated she had not seen Resident 3 since the shift began at 7 a.m. and had not administered the morning medications yet. RN 1 stated the scheduled carvedilol for 8 a.m. was missed with Resident 3's blood pressure at 124/75 (normal range 120/80). RN 1 also stated morning medications that included aspirin, carvedilol, ferrous sulfate, multivitamins, and vitamin c were not given as scheduled at 9 a.m. RN 1 stated being new and unfamiliar with the morning shift routine.During a review of Resident 3's Medication Administration Record (MAR) for September 2025, the MAR indicated Resident 3's blood pressure on 9/19/25 at 7:30 a.m. and 3:30 p.m. was 154/72.
The MAR further indicated carvedilol was scheduled to at 8 a.m. while aspirin, bupropion, multivitamins, ferrous sulfate and vitamin C were scheduled for administration at 9 a.m.During a concurrent interview and record review on 9/23/25 at 12:30 p.m. with Director of Staff Development (DSD), Resident 3's MAR for September 2025 was reviewed. DSD stated medications have a two-hour window for administration, one hour before or up to an hour after the scheduled time. DSD stated delays in administering medications could result in medical conditions, such as high blood pressure, not being addressed promptly. DSD also stated the MAR indicated elevated blood pressure readings of up to 184/92 between 9/1/25 and 9/22/25.During a review of the facility's policy and procedure (P&P) titled Medication Administration last revised 1/1/25, the P&P indicated the facility's policy aims to ensure all medications are administered safely and accurately, and that residents receive their prescribed medications in a safe, timely and effective manner.
The P&P indicated staff must adhere to the following 6 rights of medication administration: right resident, right medication, right dose, right route, right time and right documentation.
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
Facility ID:
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.