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F0839
D

Failure to Verify Nursing Licensure and Employment References

Concord, California Survey Completed on 12-11-2025

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 comply with required employment and licensure verification procedures when it hired an individual who falsely represented themselves as a Registered Nurse (RN). The individual, whose Licensed Vocational Nurse (LVN) license had been revoked in 2020, used another person's RN license with a different spelling of the first name and a missing middle name. Despite discrepancies between the individual's identification and the RN license, the facility's Human Resources (HR) representative did not identify the inconsistency during the background check and verification process, resulting in the individual being hired as an RN. Record reviews revealed that the facility did not complete or document employment and personal reference checks for the individual prior to hiring. The Director of Staff Development (DSD) and HR were responsible for verifying nursing licenses and background checks, but neither confirmed that the license verification matched the applicant's identification. The Director of Nursing (DON) was unaware of the discrepancies until the survey and stated that the facility should have verified the license online and matched it to the applicant's identification. The facility's policy required verification of nursing licenses and contacting previous employers before hiring nursing personnel. However, these procedures were not followed, and the individual was employed without a valid nursing license. The failure to verify licensure and references allowed an unlicensed individual to work as an RN, contrary to facility policy and regulatory requirements.

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