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F0835
D

Unlicensed Staff Hired and Functioning as LVN

Los Angeles, California Survey Completed on 08-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its credentialing process was completed prior to hiring a staff member as a Licensed Vocational Nurse (LVN). Staff 1 was hired and worked as an LVN for over a year and a half without a valid nursing license. Review of the personnel file showed that Staff 1 only had a California ID and Social Security card, with no evidence of LVN license verification. The Director of Staff Development (DSD) confirmed that no license verification was conducted at the time of hire, and a subsequent check revealed that Staff 1 did not hold a valid LVN license. The facility's policy required license verification before employment, but this was not followed. During this period, Staff 1 administered controlled substances, including Norco, Tramadol, and Oxycodone, to multiple residents, including a resident with osteomyelitis. The Director of Nursing (DON) and DSD both acknowledged that allowing an unlicensed individual to function as an LVN posed significant risks, including improper medication administration and inaccurate documentation. The Administrator also confirmed that the facility did not follow its own policy and that hiring an unlicensed staff member placed all residents at high risk of harm.

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