Based on interview and record review, conducted during a site visit on 04/25/25, the facility's failure to obtain background checks on all subject individuals was substantiated. Findings include, but are not limited to:

A review of Staff 2's (Caregiver) background check indicated the background check application was submitted on 09/07/23, with Staff 2 needing to have complied with fingerprinting by 10/18/23. There was a secondary request to comply on 10/23/23 and the background check was approved on 11/28/23.

In an interview, Staff 1 (Executive Director) indicated Staff 2 did not get fingerprinting done before the required compliance date of 10/18/23. Therefore, his/her background check should have been closed, and no longer allowed to work. Staff 1 indicated Staff 2 had not been pulled off the floor and had worked after 10/18/23. Staff 2 had taken his/her fingerprints on 10/26/23 and had been approved to work on 11/28/23.

The findings were reviewed with and acknowledged by Staff 1 on 04/25/25.

The facility's failure to obtain background checks on all subject individuals was substantiated.