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Facility failed to ensure the negotiated service agreement for Resident 2 was signed annually.

The facility was out of compliance regarding required vaccination records for a visiting pet, though the facility corrected this by providing documentation of the missing immunization.

Facility failed to report a resident-to-resident altercation to the Department's Complaint Resolution Unit.

Facility failed to implement resident smoking policy; smoke was observed inside the facility, posing a risk to residents and staff.

Facility failed to ensure 4 of 4 sampled staff submitted new background checks within the required two-year timeframe.

Facility failed to have qualified staff complete annual ongoing assessments for 5 of 5 residents; records were late or missing.

Facility failed to maintain the required commercial general liability insurance coverage amounts.

Facility failed to provide fire drills for 2024.