Brookdale Bend.

“Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 02/09/26, between 10:15 am and 1:15 pm, the facility kitchen was observed to need cleaning and repair in the following areas: Areas in need of cleaning and/or repair: * Fridge gasket in Claire kitchenette - loose, detached, preventing seal/door closure; * Cutting boards - heavily scored, stained, non-cleanable; * Floor under the two sinks - missing and/or loose tiles, exposed concrete, porous, non-cleanable surfaces; and * Dish machine - wash temperature below minimum required during survey, and for two consecutive days prior to survey, and staff continued to use the machine. During an observation on 02/09/26 at approximately 11:30am, Staff 1 (PIC/Dining Services Manager) demonstrated the dish machine did not meet minimum temperature requirements. Staff 1 verified that the machine had not met temperature requirements for two consecutive days prior to survey and staff had continued to use the machine. Staff planned to use the three-compartment sink for ware washing until the repair was made. During an observation on 02/09/26 at approximately 12:15 pm, surveyor observed refrigerator temperatures in the Claire kitchenette to be above the maximum required temperature and noticed the gasket was detached, keeping the door ajar. Staff 1 and Staff 3 (Maintenance Director) reported that they were unaware of the detached gasket. The surveyor observed documentation of temperatures above maximum temperature for approximately five days. Staff planned to adjust the temperature of the refrigerator, discard any potentially hazardous food, monitor temperatures, and make repairs. During record review of the temperatures of the refrigerator in the Bridge kitchenette, the surveyor noticed several temperatures above the maximum required temperatures. Staff 1, Staff 2 (Executive Director), and Staff 3 reported that they were unaware of the refrigerator being above the required temperature. Staff planned to adjust and monitor the refrigerator temperatures. The areas of concern were observed and/or discussed with Staff 1 (PIC/Dining Services Manager), Staff 2 (Executive Director), and Staff 3 (Maintenance Director). Staff acknowledged the findings at approximately 1:15 pm on 02/09/26. Facility will ensure adherance to kitchen practices and protocols in accordance with the Food Sanitation Rules OAR 333-150-000 by doing the following: - Replacing both kitchenette fridge seals and evaporator fans and cleaning the consendor motors. Motors will be cleaned every six months, and fridge gaskets will be checked every two months by Maintenance Supervisor and replaced as needed. - Purchasing new cutting boards, which will be replaced at least annually unless sooner is indicated by visible wear and tear. - Exposed concrete underneath the two-sink from a prior drain pipe repair will be replaced with a new drain. Vendor has been contacted and project is anticipated to be completed by end of March 2026. - Dishwashing machine thermostat was adjusted by EcoLab to meet temperature sanitation requirements. To prevent this violation from occurring again, staff will check the thermometer prior to each wash cycle to ensure wash temperature is at least 150 degrees and rinse temperature is at least 180 degrees. If temperature falls outside of these ranges, staff will utilize the three-sink method. - Monitoring kitchenette refrigerators by using remote app with temperature sensors, as well as ensuring refrigerators in kitchenettes are locked after each meal. Executive Director, Dining Services Coordinator and Maintenance Supervisor will be responsible to see that corrections are completed and monitored. OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. See C240. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for residents. The number of discrepancies and the severity of concerns placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to: During the re-licensure survey, conducted 11/03/25 through 11/06/25, the facility failed to ensure a safe medication system, and administrative oversight was found to be ineffective based on discrepancies and the level of severity in the following area: C 302: Systems: Tracking Controlled Substances. On 11/05/25 at 4:20 pm, the survey team informed Staff 1 (ED), Staff 2 (Health and Wellness Director, RN), and Staff 22 (District Director of Operations) that the failure to have a safe medication administration, as indicated by the extensive number of discrepancies with the narcotic tracking log and the MAR, created the potential of harm and constituted a situation that required an immediate plan of correction. The facility presented a plan of correction on 11/05/25 at 5:46 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1, Staff 2, and Staff 22 on 11/05/25. The staff acknowledged the findings. Refer to C302. OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:”

“Based on observation, interview, and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 4 of 4 sampled residents (#s 1, 2, 4, and 7) whose MARs and Controlled Substance Disposition logs were reviewed. Resident 1, 2, 4, and 7’s narcotic pain medication was not tracked effectively to ensure the medication was administered as ordered. The lack of accurate documentation of narcotic medication administrations put Residents 1 and 2 at increased risk for unaddressed pain. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C300 and C302. OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:”

“The findings of the kitchen inspection, conducted 02/22/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 02/22/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the revisit to the kitchen inspection of 02/22/24, conducted 05/08/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities. The findings of the revisit to the kitchen inspection of 02/22/24, conducted 05/08/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility main kitchen, kitchenettes, food storage areas, food preparation, and food service on 02/22/24 noted a buildup of splatters, spills, drips, and debris on: - Exteriors and interiors of reach-in refrigerators and freezers on each unit; - Exterior of cupboards and walls in unit refrigerator areas; - Floor of the walk-in refrigerators and reach in freezer in the main kitchen; - Can opener casing; and - Lids and sides of garbage cans. * Multiple packed food items were not dated when opened. * Raw eggs were stored over vegetables. * Scoops and spoons were left in bulk bins of foods. * Significantly dented canned food item noted in the dry storage. * There was not a small diameter probe thermometer to measure thin foods. * There was no evidence of monitoring the sanitizing solution to ensure it was at the correct ratio. * There was no evidence of monitoring temperatures of refrigerators, cooked foods, or the ware washer. * High temperature ware washer was not reaching the required water temperature. Staff 1 (Executive Director) and Staff 2 (Dietary Services Director) agreed to sanitize dishes in the triple pot sink until the issue was resolved. * Caregiving staff, who provided incontinent care to residents, were not using aprons while serving food. Staff 1 (Executive Director), Staff 2, and the surveyor toured the kitchens on 02/22/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility main kitchen, kitchenettes, food storage areas, food preparation, and food service on 02/22/24 noted a buildup of splatters, spills, drips, and debris on: - Exteriors and interiors of reach-in refrigerators and freezers on each unit; - Exterior of cupboards and walls in unit refrigerator areas; - Floor of the walk-in refrigerators and reach in freezer in the main kitchen; - Can opener casing; and - Lids and sides of garbage cans. * Multiple packed food items were not dated when opened. * Raw eggs were stored over vegetables. * Scoops and spoons were left in bulk bins of foods. * Significantly dented canned food item noted in the dry storage. * There was not a small diameter probe thermometer to measure thin foods. * There was no evidence of monitoring the sanitizing solution to ensure it was at the correct ratio. * There was no evidence of monitoring temperatures of refrigerators, cooked foods, or the ware washer. * High temperature ware washer was not reaching the required water temperature. Staff 1 (Executive Director) and Staff 2 (Dietary Services Director) agreed to sanitize dishes in the triple pot sink until the issue was resolved. * Caregiving staff, who provided incontinent care to residents, were not using aprons while serving food. Staff 1 (Executive Director), Staff 2, and the surveyor toured the kitchens on 02/22/24. They acknowledged the findings. Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintaned in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility main kitchen, kitchnettes, food storage areas, food preparation, and food service on 2/22/24 noted a buildup of splatters, spills, drips and debris on: - Exteriors and interiors of reach-in refrigerators and freezers on each unit; - Exterior of cupboards and walls in unit refrigerator areas; - Floor of walk-in refrigerators and reach-in freezer in the main kitchen; - Can opener casing; and - Lids and sides of garbage cans POC: ED added kitchenette cleaning to NOC shift assignment and reviewed standards/expectations for cleaning the kitchenettes. Care staff to clean nightly and Dining Services Coordinator to check weekly to ensure it is being cleaned thoroughly. Can opener casing, walk-in refrigerator and reach-in freezer cleaned immediately and added to weekly/monthly cleaning list for Dining Services Team to ensure they are on regular cleaning schedule. - Multiple packed food items were not dated when opened. POC: DSC reviewed this with cooks, disposed of undated items and ED reviewed with care staff during February all staff meeting. This will be part of daily end of shift check to ensure all items are dated and prevent reoccurrence. - Raw eggs were stored over vegetables. POC: Eggs were immediately moved to the bottom shelf. DSC reviewed this with cooks. To prevent reoccurrence, DSC/cook to check walk-in daily for temperatures, dates, and product placement (e.g. eggs on bottom shelf) at the end of each shift. - Scoops and spoons were left in bulk bins of foods. POC: Scoops and spoons removed from bulk bins. This was reviewed during February's all staff meeting with care staff, but signs have also been placed on bins reminding all staff not to store scoops/spoons in bulk bins and this will be part of the end of shift checklist for Dining Services. - Significantly dented canned food item noted in the dry storage. POC: Item moved to a separate storage location immediately to be returned to vendor. During each shipment, DSC and cooks to check for significantly dented items and to notate immediately that item is to be returned to prevent staff from accidentally using item before being returned. - There was not a small diameter probe thermometer to measure thin foods. POC: DSC located small diameter probe thermometer to use for measuring thin foods. Dining Services Team aware and will utilize moving forward. - There was no evidence of monitoring temperatures of refrigerators, cooked foods or the ware washer. POC: Temperature logs were replaced immediately. To prevent reoccurrence, Dining Services Team to take food, refrigerator and freezer temps and log them for each meal. ED to check for compliance weekly. - High temperature ware washer was not reaching the required water temperature. POC: EcoLab was contacted immediately to service machine and Dining Services Team sanitized dishes in the triple pot sink until the issue was resolved. To prevent reoccurrence, Dining Services Team to check temperature daily to ensure temps are falling within the requirements. - Caregiving staff, who provided incontinent care to residents, were not using aprons while serving food. POC: Aprons purchased and in-service held on 2/29/24 to communicate this requirement for all care staff who are serving food after providing incontinent care to residents. Management team rotating days on the floor during mealtimes to ensure compliance. Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintaned in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility main kitchen, kitchnettes, food storage areas, food preparation, and food service on 2/22/24 noted a buildup of splatters, spills, drips and debris on: - Exteriors and interiors of reach-in refrigerators and freezers on each unit; - Exterior of cupboards and walls in unit refrigerator areas; - Floor of walk-in refrigerators and reach-in freezer in the main kitchen; - Can opener casing; and - Lids and sides of garbage cans POC: ED added kitchenette cleaning to NOC shift assignment and reviewed standards/expectations for cleaning the kitchenettes. Care staff to clean nightly and Dining Services Coordinator to check weekly to ensure it is being cleaned thoroughly. Can opener casing, walk-in refrigerator and reach-in freezer cleaned immediately and added to weekly/m”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240. Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240. Refer to C 240 Refer to C 240 There are no detail notes for this visit.”

“The findings of the on-site investigation, conducted 04/09/24 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day The findings of the on-site investigation, conducted 04/09/24 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day”

“Based on interview and record review, conducted during a site visit on 02/01/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 12 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). Findings include, but are not limited to: A review of Residents 1, through 12's, Medication Administration Record (MAR), Progress notes, dated 11/03/23 through 11/12/23, and in house investigation dated 11/10/23 through 11/13/23 that was reported to APS (Adult Protective Services) confirmed the following medications were not administered. 1) Resident 1 had a physician order for Levothyroxine 0500, to administer one time daily at 5 am. Missing doses were 11/05/23, 11/07/23, 11/08/23, and 11/09/23. 2) Resident 2 had a physician order for Levothyroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 3) Resident 3 had a physician order for Levohtyroxine 0500 to administer one time daily at 5am. Missing doses were 11/04/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, and 11/11/23. 4) Resident 4 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23, and 11/12/23. 5) Resident 5 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 6) Resident 6 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 7) Resident 7 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23, 11/11/23, and 11/12/23. 8) Resident 8 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/07/23, 11/08/23, and 11/09/23. 9) Resident 9 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 10) Resident 10 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/03/23, 11/07/23, 11/08/23, and 11/09/23. 11) Resident 11 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 12) Resident 12 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23 and 11/12/23. In an interview on 02/01/24 at 10:25 am, Staff 1 (ED) and Staff 2 (Health and Wellness director) confirmed they were aware of the incident, and had reported the incident to APS as required, and the employee involved had been counseled extensively and completed multiple Relias courses on medication errors. Staff 2 stated that physicians and families were notified of the medication errors, and that residents affected were monitored and there was no negative outcome to the residents. The above information was shared with Staff 1 on 02/01/24. S/he acknowledged the findings. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal Plan of Correction: ED states that they will continue to report all medication errors to the State right away. ED states that they have provided training to all staff and went over medication errors and are reporting to MT, Administration and RN immediately. ED & RN are performing daily clinicals. Based on interview and record review, conducted during a site visit on 02/01/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 12 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). Findings include, but are not limited to: A review of Residents 1, through 12's, Medication Administration Record (MAR), Progress notes, dated 11/03/23 through 11/12/23, and in house investigation dated 11/10/23 through 11/13/23 that was reported to APS (Adult Protective Services) confirmed the following medications were not administered. 1) Resident 1 had a physician order for Levothyroxine 0500, to administer one time daily at 5 am. Missing doses were 11/05/23, 11/07/23, 11/08/23, and 11/09/23. 2) Resident 2 had a physician order for Levothyroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 3) Resident 3 had a physician order for Levohtyroxine 0500 to administer one time daily at 5am. Missing doses were 11/04/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, and 11/11/23. 4) Resident 4 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23, and 11/12/23. 5) Resident 5 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 6) Resident 6 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 7) Resident 7 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23, 11/11/23, and 11/12/23. 8) Resident 8 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/07/23, 11/08/23, and 11/09/23. 9) Resident 9 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 10) Resident 10 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/03/23, 11/07/23, 11/08/23, and 11/09/23. 11) Resident 11 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 12) Resident 12 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23 and 11/12/23. In an interview on 02/01/24 at 10:25 am, Staff 1 (ED) and Staff 2 (Health and Wellness director) confirmed they were aware of the incident, and had reported the incident to APS as required, and the employee involved had been counseled extensively and completed multiple Relias courses on medication errors. Staff 2 stated that physicians and families were notified of the medication errors, and that residents affected were monitored and there was no negative outcome to the residents. The above information was shared with Staff 1 on 02/01/24. S/he acknowledged the findings. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal Plan of Correction: ED states that they will continue to report all medication errors to the State right away. ED states that they have provided training to all staff and went over medication errors and are reporting to MT, Administration and RN immediately. ED & RN are performing daily clinicals.”

“Based on interview and record review, conducted during a site visit on 09/27/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: During an interview on 09/27/23, Staff 2 (Administrator) stated the facility is currently working with the district team to ensure that all 22 Activities of Daily Living (ADLs) are listed, for each resident in the tool. On 10/02/23, a record review of the facility's ABST report, dated 10/02/23, showed only 17 ADLs were listed for each resident. The occupancy listed on the tool was 49 and the census on 10/02/23 was 49. The findings of the investigation were reviewed with and acknowledged by Staff 2 on 09/27/23. It was determined the facility failed to fully implement an Acuity-Based Staffing Tool. Verbal Plan of Correction: The district team is working to include all 22 ADLs in the tool. Projected date of compliance unknown. Based on interview and record review, conducted during a site visit on 09/27/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: During an interview on 09/27/23, Staff 2 (Administrator) stated the facility is currently working with the district team to ensure that all 22 Activities of Daily Living (ADLs) are listed, for each resident in the tool. On 10/02/23, a record review of the facility's ABST report, dated 10/02/23, showed only 17 ADLs were listed for each resident. The occupancy listed on the tool was 49 and the census on 10/02/23 was 49. The findings of the investigation were reviewed with and acknowledged by Staff 2 on 09/27/23. It was determined the facility failed to fully implement an Acuity-Based Staffing Tool. Verbal Plan of Correction: The district team is working to include all 22 ADLs in the tool. Projected date of compliance unknown.”