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 (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: 555104 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 555104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Post Acute 1050 San Miguel Road Concord, CA 94518 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)