C4905

Missing Staff Health Exam Documentation

Rinaldi Convalescent HospitalGranada Hills, California Survey Completed on 10-09-2025

Summary

The facility failed to ensure that the personnel files for several certified nursing assistants (CNAs) and licensed vocational nurses (LVNs) contained documentation of required health examinations either 90 days prior to or within seven days after hire, as well as annual health exams thereafter. Specifically, the records for five CNAs and two LVNs did not include evidence of a health exam completed within the required timeframe upon hire. Additionally, the files for two LVNs lacked documentation of annual health exams after their initial employment.

During interviews, both the Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged the absence of medical clearance for these staff members. The DSD confirmed that it is now her practice to ensure compliance with health exam requirements for new hires and annual reviews. The facility's policies and procedures require maintenance of personnel records in accordance with state and federal regulations, including documentation of the ability to perform essential job functions, but these were not followed in the cited cases.

Plan Of Correction

A) IMMEDIATE CORRECTIVE ACTION:
On 10/09/2025, DSD immediately contacted CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, LVN 1, and LVN 2 to notify them that they may not return to work until a physical exam is completed. She referred them to a clinic that completed their physicals and provided the facility with their clearance and ability to work. Staff were returned to work upon providing their physical exams to the DSD and/or Administrator.

B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE:
On 10/8/2025, DSD and Assistant DSD reviewed all other CNA and LVN files to ensure the presence of a health exam within the last 12 months.

C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR:
Effective 10/30/2025, DSD will review all CNA and LVN anniversary dates monthly to ensure annual health exams are completed timely and as per facility protocol.

D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED:
The DSD/Designee will present monthly health exam completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance.

E) COMPLETION DATE: 10/31/2025

Penalty

No penalty information released