Mercy Retirement & Care Center
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
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.
Residents Affected - Few
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
Event ID:
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.