Health inspection·December 11, 2025

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure compliance with required employment and licensure verification procedures when a previous staff member, who falsely represented themselves as a Registered Nurse (RN), used another person's RN license, and had a revoked Licensed Vocational Nurse (LVN) license in 2020 was hired and employed by the facility.These failures had the potential to place residents at risk for harm including medication errors, delays in necessary nursing interventions, and improper clinical decision-making by unlicensed nursing personnel.During a record review of Unlicensed Nurse (UN) 1's employee file, a printed copy of the RN nursing license dated 8/28/23, reflected a missing middle name and different spelling of the first name than that of UN 1. The RN nursing license copy further indicated it was generated and printed approximately five months prior to UN 1's application for RN position at the facility.During a record review of UN 1's Offer Letter, dated 1/31/24 from the facility, the Offer Letter showed UN 1 was offered a full-time RN position for the PM shift (3:00 p.m. to 11:30 p.m.) The Offer Letter further indicated UN 1 signed and accepted the offer on 1/31/24.During a record review of UN 1's record, titled, Background Report (BR), dated 2/6/24, the Professional License verification reflected that UN 1's identity did not match the name listed on the nursing license. The Professional License report showed the license belonged to a different RN with a similar name; however, the first name was spelled differently, and the individual had a different middle name.During a record review of UN 1's record, titled, Job Description: RN, dated 1/31/24, UN 1 signed the RN job description that specified, Must possess, as a minimum, a Nursing Degree an accredited college or university.Must possess a current, unencumbered, active license to practice as an RN in this state.Must remain in good standing with the Sate Board of Nursing at all times.During a record review of the facility's untitled document, dated 1/30/25, the record showed UN 1 was employed at the facility from 1/31/24 to 2/11/24.During a record review of UN 1's publicly available nursing license verification record, dated 12/12/25, the record indicated UN 1's LVN license had been revoked on 6/10/20, and UN 1's right to practice nursing was removed.During a record review and interview on 12/3/25 at 11:54 a.m. with the facility's Human Resources representative (HR) 1, UN 1's BR dated 2/6/24 was reviewed. HR 1 stated, as part of the background check and verification process, two forms of valid identification were required from UN 1. HR 1 further stated she was unable to explain why UN 1's license verification reflected a name different from the two forms of identification provided by UN 1. HR 1 stated the discrepancy was missed during the review process, and as a result, UN 1 was hired by the facility without a verified active nursing license. HR 1 stated employing an individual without a verified nursing license posed a risk to resident care and represented a significant liability to the facility. HR 1 further stated maintaining an active nursing license was essential to ensure nurses could provide appropriate care and support to residents.During a record review and interview on 12/2/25 at 2:39 p.m. with the Administrator (ADM), UN 1's BR dated 2/6/24 was reviewed. ADM stated HR and DSD were responsible for double-checking information received Residents Affected - Few Page 1 of 2 555104 555104 12/11/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the background check company. ADM further stated he would have investigated had discrepancies been identified between UN 1's name on the provided identification and the nursing license.During a record review and interview on 12/8/25 at 12:30 p.m. with Director of Staff Development (DSD), UN 1's employee file, including the application dated 1/22/24, was reviewed. DSD stated the facility was unable to verify that employment and personal reference checks were completed prior to hiring UN 1 due to the absence of documentation. DSD further stated reference check should have been conducted to verify UN 1's prior work history and to assess work performance and behavior.During a record review and interview on 12/11/25 at 9:33 a.m. with the Director of Nursing (DON), UN 1's employee file, including Application for Employment dated 1/22/24, BR dated 2/6/25, and UN 1's printed copy of nursing license dated 8/28/23, were reviewed. The DON stated prior to hiring a nursing personnel, the facility was responsible for ensuring the individual held an active nursing license and cleared of all the required background checks before working in the facility. The DON stated this was her first time becoming aware of the discrepancies with UN 1's identity and the nursing license UN 1 provided. The DON stated the facility should have verified the nursing license online and matched the identification provided to confirm the license belonged to UN 1. The DON further emphasized that conducting reference checks for all employees was essential to determine whether an applicant was reliable, trustworthy, and had demonstrated satisfactory performance in previous employment.During a follow up interview on 12/11/25 at 9:49 a.m. with DSD, DSD stated she was responsible for verifying nursing licenses online as part of the hiring process but was unable to recall if she had checked UN 1's nursing license prior to hiring. DSD stated HR 1 was responsible for ensuring that an applicant was cleared to work at the facility following completion of the background check, which included license verification. DSD further stated once HR 1 confirmed an applicant was cleared, she would proceed with finalizing the hire without conducting any additional verification herself. During a follow up interview on 12/11/25 at 10:03 a.m. with the DON, the DON stated hiring unlicensed nursing personnel posed several risks due to the individual's potential inability to perform required nursing duties and negatively impact resident care. The DON further stated if a nursing license was revoked, it indicated prior misconduct, and hiring such individual created a risk of similar issues occurring within the facility. During a record review of the facility's policy and procedures (P&P), titled, Credentialing of Nursing Service Personnel, dated May 2019, the P&P indicated, Nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment.Upon obtaining the applicant's informed to conducting a license/certification/background investigation, the DON services, or designee, will.a. contact the appropriate state licensing board(s) to obtain a letter of verification/computer printout of such license/certification.c. contact previous employers to obtain written/oral verification of previous work experience and qualifications.5. Should the investigation reveal inconsistencies in information obtained and information provided by the applicant that would prevent the applicant's further employment.6. Should the investigation reveal the applicant does not hold a valid license or certification, appropriate state licensing boards and authorities will be notified of the applicant's attempt to practice without a license/certification. 555104 Page 2 of 2