**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5RN (Registered Nurse) asked Resident #36, who was cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 74 residents residing in the facility. S1 Administrator was notified of the Immediate Jeopardy on 02/06/2025 at 3:30 p.m. The Immediate Jeopardy was removed on 02/07/2025 at 4:45 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Review of the facility's Incident Investigation and Reporting policy with a last review date of 05/2024, revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH (Louisiana Department of Health), Health Standards Section, local law enforcement, and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. 1. Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property . Relevant terms - Sexual abuse: Is nonconsensual sexual contact of any type with a resident. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part bipolar disorder, major depressive disorder-single episode severe with psychotic features, anxiety disorder, intellectual disabilities and delusional disorders. Review of Resident #2's most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #2 had a BIMS (Brief Interview for Mental Status) score of 09 out of 15 indicating moderate cognitive impairment. Resident #2 used antipsychotic medication on a routine basis. Resident #2 required set-up help by staff for mobility and transfers. Review of Resident #2's comprehensive care plan failed to reveal that any interventions or monitoring following the incident of sexual abuse on 09/08/2024 had been implemented. Resident #36 Resident # 36 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified dementia, moderate, with other behavioral disturbances, schizophrenia unspecified, Alzheimer's disease with late onset, and major depressive disorder, recurrent, severe. Review of Resident #36's Quarterly MDS assessment dated [DATE] revealed in part, Resident #36 had a BIMS score of 03 out of 15 indicating severely impaired cognition. Resident #36 was able to walk 150 feet with supervision and utilized a wheelchair as a mobility device. Review of Resident #36's comprehensive care plan failed to reveal protective measures had been implemented related to an incident of unwanted sexual contact by Resident #2. Review of Resident #36's medical record revealed, a nurse's note by S5 RN dated 09/08/2024 at 9:24 p.m. which read in part, S4 CNA reported to S5 RN that Resident #36 was being felt on in dining room by a male resident (Resident #2). Resident #36 found in dining room, lights off, standing in front of Resident #2's walker. When asked what was going on, Resident #2 was silent. Both residents separated. S5 RN asked, Were you (Resident #36) being touched by him (Resident #2)? Resident #36 stated, Well yeah, just down here as she (Resident #36) pointed to my (S5 RN) breast. S5 RN asked if she (Resident #36) wanted that to happen. She (Resident #36) stated, No. S5 RN asked if she (Resident #36) was uncomfortable; she (Resident #36) stated, Yes . Resident #36 sent to room, in stable condition. Review of an incident report dated 09/08/2024 at 9:00 p.m. related to Resident #2, and prepared by S5 RN revealed in part: Description: S4 CNA reported to S5 RN that Resident #2 was sitting in dining room with a female resident (Resident #36), Resident #2 grabbed her hand, pulled her close and began to feel on her breast. S4 CNA reports that she knocked on the window and Resident #2 stopped. S5 RN entered dining area; Resident #2 was sitting and Resident #36 was standing in front of him and his walker. S5 RN asked Resident #2 if he touched Resident #36's breasts. Resident #2 stated, I'm sorry, I won't do it again, I didn't mean it, I'm sorry. S5 RN explained that these actions were inappropriate and actions would have to be reported. Resident #2 continues to apologize. Resident #2 encouraged to head to bed but Resident #2 refused multiple times, Resident #2 stated, It's too early, I'm going to the TV room . Review of the facility's reportable incident list 05/01/2024 to 02/03/2025 failed to reveal a report of sexual abuse on 09/08/2024 had been submitted to the appropriate state agency for review. During an interview on 02/04/2025 at 1:00 p.m., S2 DON (Director of Nursing) reported she was unable to find any ongoing monitoring of Resident #2. S2 DON identified the staff involved in the reporting of the incident as S5 RN and S4 CNA, neither still work at the facility. S2 DON identified the victim as Resident #36. During an interview on 02/04/2025 at 4:30 p.m., S2 DON reported she had not provided in-service training to all staff on abuse and neglect following the incident with Resident #2 and should have. During a telephone interview on 02/06/2025 at 3:00 p.m., S4 CNA reported she was walking by the glassed-in dining room directly adjacent from the nurse's station and happened to notice Resident #2 and #36 in the dining room. Resident #36 was standing in front of Resident #2. She stopped to see what was going on because the lights were off and she saw Resident #2 playing with Resident #36's breast. She banged on the dining room window and called the nurse/S5 RN who immediately went in the dining room and separated them. S4 CNA reported she was not aware of any in-services done at the time or right after the incident about abuse. During an interview on 02/06/2025 at 10:50 a.m., S1 Administrator acknowledged she was not made aware of the sexual abuse incident of Resident #36 being inappropriately touched by Resident #2, until 02/04/2025. S1 Administrator reported she was out during the incident date and she had not been informed upon return. S1 Administrator acknowledged a report was never submitted to the appropriate state agency or law enforcement and should have been. During an interview on 02/06/2025 at 11:05 a.m., S2 DON reported she was working on the night of the incident and conducted an abuse in-service on 09/08/2024 with the on-site evening shift and oncoming night shift staff but had not in-serviced the day shift or remaining staff members on abuse. S2 DON acknowledged she was responsible for in-servicing the staff on the abuse/neglect policy including recognizing signs, investigations, protection, and reporting procedures and failed to ensure all staff had been in-serviced. S2 DON reported she was responsible for overseeing that interventions were put into place to protect the residents but she had not reviewed the assessments and monitoring findings and should have. S2 DON acknowledged she did not notify the Administrator of the sexual abuse allegations towards Resident #36 or report it to the appropriate state agency or law enforcement and should have. During an interview on 02/06/2025 at 11:20 a.m., S3 Corporate Nurse reported she was notified of the incident by the DON the following day 09/09/2024. S3 Corporate Nurse acknowledged S1 Administrator had never been informed of the sexual abuse incident and she should have made sure S1 Administrator was made aware. S3 Corporate Nurse reported she would be responsible to oversee the monitoring. S3 Corporate Nurse acknowledged she had not confirmed the completion of ongoing monitoring. During an interview on 02/07/2025 at 10:30 a.m., S2 DON acknowledged no interventions had been put into place for the safety of Resident #36 or all other residents related to the sexual abuse incident and should have been. During an interview on 02/06/2025 at 4:00 p.m., S1 Administrator and S3 Corporate Nurse acknowledged the facility failed to properly report the allegation of sexual abuse and appropriately monitor the situation and should have. The facility's Plan of Removal: Resident #36 and all other residents have the potential for similar outcome. Two residents were unsupervised in the facility dining room with lights off on 09/08/2024. S4 CNA witnessed in the facility dining room with lights off Resident #2 touching Resident #36's breast. Resident #2 and Resident #36 were immediately separated by S4 CNA and S5 RN. Resident #2 was placed on one-on-one supervision until NP (Nurse Practitioner) saw him 09/09/2024. On 09/08/2024 Resident #36 had body audit completed by RN with no bruising, discoloration or skin impairment. Facility will ensure on February 6, 2025 residents are free from sexual abuse to prevent the likelihood of serious injury, serious harm, serious impairment or death. On February 6, 2025 the facility conducted body audits on all twenty-five cognitively impaired female residents. On February 6 and 7, 2025 Facility interviewed 8 male and 27 female residents who were interviewable to ensure there has been no other occurrence. On February 5, 2025 facility began immediately all facility staff in-servicing on how to report allegation of abuse/suspicion of inappropriate sexual conduct and who to report the allegation of abuse/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. The facility will include in Resident #2's care plan and task behaviors q (every) 2 hours to be monitored by staff. The DON or designee will review behaviors five days a week beginning 02/07/2025 with ongoing monitoring. Resident #2's plan of care has been reviewed/revised with increased supervision. Any resident that exhibits inappropriate sexual behavior will have an individualized Person-Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. Beginning February 7, 2025 nursing staff will visually observe Resident #2 every two hours for increased supervision and will be ongoing. The Regional Supervisor conducted an in-service on 02/06/2025 at 5:00 p.m. with Department Head Staff to include Administrator/Abuse Coordinator, DON, Department Staff on Abuse & Neglect, Elder Justice Act, Review of corporate training video on Abuse and Neglect, State Agency and Law Enforcement. These Department heads will conduct further training of staff during monthly staff meeting. Regional Corporate Supervisors will oversee to ensure compliance. Administrator/designee began in-servicing all facility staff beginning on February 5, 2025 on how to report allegations of abuse/suspicion of any type of abuse to include inappropriate sexual conduct and who to report the allegation/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. This in servicing began on February 5, 2025 at 4:00 p.m. and will continue until all staff have been in-serviced. All Residents that exhibit inappropriate sexual behavior will be monitored by all staff beginning on February 6, 2025. The facility Abuse Coordinator plans to monitor staff competency by direct observation, and continued in-servicing. All residents will be monitored for through direct observations, interviews and staff interviews 5 times per week and documenting effects on a facility QA (Quality Assurance) tool. These audits will continue until substantial compliance is achieved and monthly times two months. QA monitoring tools were initiated on February 6, 2025 and will be ongoing. On February 6, 2025 the Facility conducted an Emergency QA with the facility Medical Director's Nurse Practitioner to outline all a fore mentioned protocol. The QA will be on going until substantial compliance is achieved. Any residents that exhibit inappropriate sexual behavior will have an individualized/Person Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. QAPI (Quality Assurance Performance Improvement) was initiated on February 6, 2025, along with corrective action plan and monitoring tools. QA Committee will review in next Quarterly Meeting with Medical Director in attendance to give guidance and input to QA program. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 02/07/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an alleged violation of sexual abuse was reported immediately to the facility's administrator, to the appropriate state agency within 2 hours after the allegations were made and to local law enforcement for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5 RN (Registered Nurse) asked Resident #36, who is cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 74 residents residing in the facility. S1 Administrator was notified of the Immediate Jeopardy on 02/07/2025 at 11:10 a.m. The Immediate Jeopardy was removed on 02/07/2025 at 5:15 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Review of the facility's Incident Investigation and Reporting policy with a last review date of 05/2024, revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH (Louisiana Department of Health), Health Standards Section, local law enforcement, and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. 1. Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property . Relevant terms - Sexual abuse: Is nonconsensual sexual contact of any type with a resident. 3. Abuse, Neglect .are crimes and shall be reported to proper authorities as such. In the event of any incident involving an allegation or suspicion of mistreatment, exploitation, neglect, abuse ., each occurrence will be reported immediately to the Administrator of the Facility . The Administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report not later than 2 hours after forming the suspicion. 5. Additional incidents that must have a thorough investigation and may require reporting, as determined by the NF (Nursing Facility) especially in consideration to abuse and/or neglect, to the state agency with the implementation of corrective action(s), and referrals, as appropriate to the appropriate authorities/agencies. 6. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse. 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. Resident # 36 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified dementia, moderate, with other behavioral disturbances, schizophrenia unspecified, Alzheimer's disease with late onset, and major depressive disorder, recurrent, severe. Review of an incident report dated 09/08/2024 at 9:00 p.m. related to Resident #2, and prepared by S5 RN revealed in part: Description: S4 CNA reported to S5 RN that Resident #2 was sitting in dining room with a female resident (Resident #36), Resident #2 grabbed her hand, pulled her close and began to feel on her breast. S4 CNA reports that she knocked on the window and Resident #2 stopped. S5 RN entered dining area; Resident #2 was sitting and Resident #36 was standing in front of him and his walker. S5 RN asked Resident #2 if he touched Resident #36's breasts. Resident #2 stated, I'm sorry, I won't do it again, I didn't mean it, I'm sorry. S5 RN explained that these actions were inappropriate and actions would have to be reported. Resident #2 continues to apologize. Resident #2 encouraged to head to bed but Resident #2 refused multiple times, Resident #2 stated, It's too early, I'm going to the TV room . Review of the facility's reportable incident list 05/01/2024 to 02/03/2025 failed to reveal a report of sexual abuse on 09/08/2024 had been submitted to the appropriate state agency for review. Review of Resident #2's record failed to reveal a police report had been completed or police had been notified. During an interview on 02/06/2025 at 10:50 a.m., S1 Administrator acknowledged she was not made aware of the sexual abuse incident of Resident #36 being inappropriately touched by Resident #2, until 02/04/2025. S1 Administrator reported she was out during the incident date and she had not been informed upon return. S1 Administrator acknowledged a report was never submitted to the appropriate state agency or law enforcement and should have been. During an interview on 02/06/2025 at 11:05 a.m., S2 DON (Director of Nursing) confirmed she was working on the night of the incident. S2 DON acknowledged she did not notify the Administrator of the sexual abuse allegations towards Resident #36 by Resident #2 or report it to the appropriate state agency or law enforcement and should have. During an interview on 02/06/2025 at 11:20 a.m., S3 Corporate Nurse reported she was notified of the incident by the DON the following day 09/09/2024. S3 Corporate Nurse acknowledged S1 Administrator had never been informed of the sexual abuse incident and she should have made sure S1 Administrator was made aware. During an interview on 02/06/2025 at 4:00 p.m., S1 Administrator and S3 Corporate Nurse acknowledged the facility failed to properly report the allegation of sexual abuse. The facility's Plan of Removal: Resident #36 was the victim at the time of the event on 09/08/2024 at 9:00 p.m. The perpetrator, Resident #2 continues to reside in the facility. Resident #36 and all residents with an adverse event or incident that required reporting to the Administrator, State Agency and Law Enforcement. Education began on February 5, 2025, the Administrator began immediately in-servicing all facility staff on how to report an allegation of abuse, including the two hour time line to report with ongoing monitoring. The Regional Supervisor conducted an in-service on 02/06/2025 at 5:00 p.m. with the Administrator/Abuse Coordinator, DON, Corporate Nurse and Department Heads on timeline reporting requirements of two hours for any allegation or suspicion of adverse event or incident that requires reporting to the Administrator, State Agency and Law Enforcement. Education included Abuse & Neglect, Elder Justice Act, Review of corporate training video on Abuse and Neglect, State Agency and Law Enforcement. These Department heads will conduct further training of staff during monthly staff meeting. On February 7, 2025, nursing staff was in-serviced on a Reporting Decision Tree, which was placed at the nurse's station to give additional guidance to staff on reporting requirements. The facility Administrator will report within two hours, any allegation or suspicion of adverse event or incident that requires reporting to state agency and law enforcement. Monitoring: Regional Corporate Supervisors will oversee to ensure compliance. On February 6, 2025 the Facility conducted an Emergency QA (Quality Assurance) with the facility Medical Director's Nurse Practitioner to outline all aforementioned protocol. The QA will be on-going until substantial compliance is achieved. The facility will report within two hours any allegation or suspicion of abuse to State reporting office and Law Enforcement. QAPI (Quality Assurance Performance Improvement) was initiated on February 6, 2025, along with corrective action plan and monitoring tools. QA Committee will review in next Quarterly Meeting with the Medical Director in attendance, to give guidance and input to QA program. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 02/07/2025.

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. The facility failed to have an effective system in place to: 1. protect Resident #36 from sexual abuse by Resident #2 and ensure all residents were free from abuse; 2. report abuse to the appropriate state agency and law enforcement. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's glassed-in, unlit dining room. S5 RN (Registered Nurse) asked Resident #36, who is cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 74 residents residing in the facility. S1 Administrator was notified of the Immediate Jeopardy on 02/06/2025 at 3:30 p.m. The Immediate Jeopardy was removed on 02/07/2025 at 4:45 p.m. Findings, Cross reference F600 and F609: During an interview on 02/04/2025 at 1:00 p.m., S2 DON (Director of Nursing) reported she was unable to find any monitoring of Resident #2. During an interview on 02/04/2025 at 4:30 p.m., S2 DON reported she had not provided in-service training to all staff on abuse and neglect following the incident with Resident #2 and should have. During an interview on 02/06/2025 at 10:50 a.m., S1 Administrator acknowledged she was not made aware of the sexual abuse incident of Resident #36 being inappropriately touched by Resident #2, until 02/04/2025. S1 Administrator reported she was out during the incident date and she had not been informed upon return. S1 Administrator acknowledged a report was never submitted to the appropriate state agency or law enforcement and should have been. During an interview on 02/06/2025 at 11:05 a.m., S2 DON reported she was working on the night of the incident and conducted an abuse in-service on 09/08/2024 with the on-site evening shift and oncoming night shift staff but had not in-serviced the day shift or remaining staff members on abuse. S2 DON acknowledged she was responsible for in-servicing the staff on the abuse/neglect policy including recognizing signs, investigations, protection, and reporting procedures and failed to ensure all staff had been in-serviced. S2 DON reported she was responsible for overseeing that interventions were put into place to protect the residents but she had not reviewed the assessments and monitoring findings and should have. S2 DON acknowledged she did not notify the Administrator of the sexual abuse allegations towards Resident #36 or report it to the appropriate state agency or law enforcement and should have. During an interview on 02/06/2025 at 11:20 a.m., S3 Corporate Nurse reported she was notified of the incident by the DON the following day 09/09/2024. S3 Corporate Nurse reported she should have made sure S1 Administrator was made aware of the sexual abuse incident and she did not. S3 Corporate Nurse acknowledged she was responsible for overseeing the ongoing monitoring put into place and could not confirm the findings or completion of the monitoring. During an interview on 02/07/2025 at 10:30 a.m., S2 DON acknowledged no interventions had been put into place for the safety of Resident #36 or all other residents related to the sexual abuse incident and should have been. During an interview on 02/06/2025 at 4:00 p.m., with S1 Administrator and S3 Corporate Nurse, S1Administrator acknowledged she was responsible for providing oversight of the facility's abuse/neglect policy including reporting timeframes and making sure staff was educated on the necessary steps to ensure the safety and well-being of all residents. S1 Administrator and S3 Corporate Nurse acknowledged the facility failed to properly report the allegation of sexual abuse and appropriately monitor the situation and should have. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. The facility's Plan of Removal: Resident #36 and all other residents has the potential for similar outcome. On February 5, 2025 the facility began immediate all facility staff in-servicing on how to report allegation of abuse/suspicion of inappropriate sexual conduct and who to report the allegation of abuse/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. The facility will include in Resident #2's care plan and task behaviors q (every) 2 hours to be monitored by staff. The DON or designee will review behaviors five days a week beginning 02/07/2025 with ongoing monitoring. Resident #2's plan of care has been reviewed/revised with increase supervision. Any resident that exhibits inappropriate sexual behavior will have an individualized Person-Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. Beginning February 7, 2025 nursing staff will visually observe Resident #2 every two hours for increase supervision and will be ongoing. Beginning on February 7th Facility Administrator will conduct monthly in-services continuing to educate staff on abuse and reporting requirements. On February 7, 2025 signs will be placed in designated areas as reminder on reporting abuse and signs of abuse. All facility staff will be in-serviced immediately beginning on February 5,2025 on how to report allegation of abuse/suspicion of any type of abuse and who to report the allegation/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. This in servicing began on February 5, 2025 at 4:00 p.m. and ongoing until all staff have been in-serviced. Any residents that exhibit inappropriate sexual behavior will be monitored by all staff beginning on February 6, 2025. The facility Abuse Coordinator plans to monitor staff competency by direct observation, continued in-servicing, and resident and staff interviews 5 times per week and documenting effects on a facility QA (Quality Assurance) tool. These audits will continue until substantial compliance is achieved and monthly times two months. QA monitoring tools were initiated on February 6, 2025. The Regional Supervisor conducted an in-service on 02/06/2025 at 5:00 pm with Department Head Staff to include Administrator/Abuse Coordinator, DON on Abuse &Neglect, Elder Justice Act, Review of corporate training video on Abuse and Neglect, State Agency and Law Enforcement. These Department heads will conduct further training of staff during monthly staff meeting. Regional Corporate Supervisors will oversee to ensure compliance. On February 6, 2025, the facility conducted an Emergency QA with the facility Medical Director's Nurse Practitioner to outline all a fore mentioned protocol. The QA will be ongoing until substantial compliance is achieved. Any residents that exhibit inappropriate sexual behavior will have an individualized/Person Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed in capable of making consent. QAPI (Quality Assurance Performance Improvement) was initiated on February 6, 2025, along with corrective action plan and monitoring tools. QA Committee will review in next Quarterly Meeting. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 02/07/2025.