Based on interview and record review, during a site visit conducted on 06/26/24, it was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty assigned within 30 days of hire. Findings include but are not limited to:

During an interview on 03/19/24, Staff 1 (Health and Wellness Director), indicated physical copies of staff training records had gotten lost, the facility had been working on recompleting the training. Staff 11 had completed his/her 30-day competency for caregiver and med tech however forgot to turn in their training records before leaving on vacation.

There was no documented evidence the following care staff had demonstrated satisfactory performance prior to performing any duties assigned, or within 30 days of hire:

·Staff 9 (CG) Date of Hire: 05/01/24.

·Staff 10 (MT) Date of Hire: 05/08/24.

·Staff 11 (MT) Date of Hire: 05/06/24.

·Staff 12 (MT) Date of Hire: 05/01/24.

It was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty assigned within 30 days of hire.

On 06/14/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility indicated all staff are fully trained but that some training documents had been lost. The facility will audit all staff training and if unavailable staff will compete missing training and document, it has been completed.