**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 a staff member for 1 (Resident #1) of 3 (Resident #1, #2, #3) sampled residents. The facility failed to ensure S3 CNA (Certified Nursing Assistant), Resident #1's primary CNA and caregiver, did not commit abuse of power when she engaged in sexual relations with Resident #1 in his bed. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. Resident #1 with a diagnosis of aphasia, had limited speech, could make his needs known and his cognition was intact. Resident #1 reported he had sex with S3 CNA which was consensual. Nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse or power. Even though there was no significant decline in Resident #1's mental 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 abused in this manner in his own home or a health care facility. S1 Administrator, S2 DON (Director of Nursing), and S5 Corporate Nurse were notified of the Immediate Jeopardy on 03/14/2025 at 6:42 p.m. The Immediate Jeopardy was removed on 03/17/2025 at 12:50 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 Abuse/Neglect Prevention Program (Revised on 09/08/2021) revealed: ABUSE/NEGLECT POLICY STATEMENT The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. Resident #1 was initially admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, bipolar disorder, other recurrent depressive disorders, and aphasia following cerebral infarction. Review of Brief Interview for Mental Status (BIMS) conducted on 3/5/2025 after the incident revealed Resident #1 had a BIMS score of 13, which indicated Resident #1 was cognitively intact. Review of Resident #1's 12/05/2024 Quarterly MDS (Minimum Date Set) revealed Resident #1 required extensive assistance with 1 person physical assist with bed mobility, transfers, and toilet use. Review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for: Depression with interventions that included, in part, monitor for behaviors and side effects of psychotropic medication and notify MD (Medical Doctor) with noted side effects and takes Zoloft and Lexapro for depression. Verbal communication impaired related to aphasia - resident #1 is aware of what is being said to Resident #1, he uses one or two word answers yeah and no. He grunts and shakes head appropriately to asked questions by staff, uses hand motions to make his point known. Interventions included, in part, ask questions that require yes or no answers, allow resident plenty of time to respond, use simple direct communication and speak directly in front of resident. Attempts to contact S3 CNA by phone on 03/12/2025 at 4:49 p.m., 03/13/2025 at 9:03 a.m., and 03/17/2025 at 10:51 a.m. were unsuccessful. During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she went in to Resident #1's room to speak with S3 CNA and upon entering the room S3 CNA had the right side of S3 CNA's pants, underwear and shoes off and was on top of and straddling Resident #1 having intercourse. S4 CNA further reported Resident #1 and S3 CNA looked up at S4 CNA and continued having intercourse. S4 CNA also reported she left out of Resident #1's room to report what she saw to the nurse. During a phone interview on 03/13/2025 at 9:36 a.m. S6 LPN (Licensed Practical Nurse) reported S4 CNA had reported that S3 CNA was observed on top of Resident #1 in Resident #1's bed having sex with Resident #1. S6 LPN further reported she immediately reported the incident to S7 RN (Registered Nurse) and S7 RN told S3 CNA to leave the facility now. During an interview on 03/13/2025 at 1:05 p.m. Resident #1 was asked if Resident #1 had sex with S3 CNA and Resident #1 responded yes. During an interview on 03/13/2025 at 1:16 p.m. S2 DON reported she became aware of the incident between Resident #1 and S3 CNA after S6 RN called to report it. Further reported, by the time she arrived at the facility, S3 CNA had already left the facility. S2 DON and S9 ADON (Assistant Director of Nursing) conducted a full body audit on Resident #1 with no injuries noted. During an interview on 03/13/2025 at 8:10 a.m. S1 Administrator reported he had received a call around 6:25 a.m. the morning of the incident between Resident #1 and S3 CNA and was notified S3 CNA was found having sex with Resident #1. Further reported he arrived at the facility around 7:00 a.m. Also reported he had spoken with S3 CNA by phone and S3 CNA had reported 3 CNA was doing peri care and Resident #1 pulled S3 CNA toward Resident #1 and nothing happened. S1 Administrator further reported the facility did not report the incident between Resident #1 and S3 CNA because he did not recognize it was abuse because it was consensual. During an interview on 03/17/2025 at 2:15 p.m. S1 Administrator and S5 Corporate Nurse confirmed the incident that occurred between Resident #1 and S3 CNA on 03/01/2025 was sexual abuse and that a sexual relationship of staff with a resident was not consistent with the staff member's role as a caregiver and was considered an abuse of power. During an interview on 03/17/2025 at 2:35 p.m. S2 DON confirmed the incident that occurred between Resident #1 and S3 CNA on 03/01/2025 was sexual abuse and that a sexual relationship of staff with a resident was not consistent with the staff member's role as a caregiver and was considered an abuse of power. The facility's Plan of Removal: Resident # 1 was the resident identified as the recipient involved in the noncompliance. All residents have the potential to be affected by this noncompliance. No other residents at the facility were noted to have been affected by this noncompliance Specific changes to the facility's abuse and neglect policy were reviewed and updated on 03-14-2025 to include the following statements: Nursing facility staff are entrusted with the responsibility to protect and care for the residents of the facility. Nursing facility staff are expected to recognize that engaging in a sexual relationship with a resident, even a willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. Changes to this policy were in-serviced to the nursing facility staff beginning the evening of 03-14-2025 and will continue until all staff of the facility have been in-serviced and have had a baseline competency interview. Date and time action taken: 03-14-2025 Prior to survey entrance on 03-12-2025 and prior to the Immediate Jeopardy being called on 03-14-2025 the facility completed the following tasks: 03-01-2025: The accused employee clocked out at 6:17 a.m., immediately after nurse informed of event, pending the investigation. Nursing administration and Administrator came to the facility and took the following steps: The resident was examined for injury (none noted), he was then interviewed by the administrator. Resident #1 did not exhibit any signs of fear, sadness, nor was he emotionally upset The witness to the event was interviewed by administration, and the accused was interviewed, via telephone. Inservices were started for all staff on 03-01-2025 regarding abuse and neglect, including sexual abuse. These inservices continued on until 03-03-2025 attempting to reach all staff members, using a employee roster. Nursing administration began interviewing all interviewable residents to see if they had witnessed or had a sexual encounter with a staff member. None were reported. Also on 03-01-2025 all non-interviewable staff were physically examined for any evidence of a sexual encounter. None of the assessments indicated a sexual encounter had occurred. In addition, staff interviews were conducted to see if they had witnessed or had knowledge of any staff sexual encounters, none were witnessed or had knowledge of any staff to resident sexual encounters. Resident #1 was assigned to have 2 employees care for him on 03-01-2025 and continuing thereafter. Resident #1's RP (Responsible Party) and NP (Nurse Practitioner) were made aware of the situation. 03-03-2025: the administrator met with the resident council and offered to discuss any concerns the residents had regarding the questions asked over the weekend and told them to please come to him or nursing staff if they had any issues they wanted to discuss. 03-03-2025: Resident #1's NP with a mediation change (increasing his antidepressant). The accused was formally terminated from the facility. 03-04-2025: the facility psych NP visited the resident and the facility's SSD (Social Services Director) reached out to in house counseling services to see if Resident #1 is eligible to have in-house counseling related to this event. Monitoring of residents and staff was implemented using the post event monitor and asking questions to see if any inappropriate staff sexual behavior had been witnessed or suspected. This was happening 3 times a week for 6 weeks and then monthly thereafter until compliance was assured. Also the event and corrective actions were being discussed at the QAPI (Quality Assurance and Performance Improvement) meeting weekly with any corrective actions that were implemented based on the interviews being discussed. Completion Date of these actions was 03-04-2025 Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 03/17/2025

Based on record review and interviews the facility failed to develop and implement written policies and procedures that included immediate response to protect an alleged victim from physical and psychosocial harm during and after an investigation. The facility failed to ensure Resident #1 was provided immediate protections after S4 CNA (Certified Nursing Assistant) witnessed S3 CNA engaging in sexual relations with Resident #1. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. S4 CNA immediately left out of Resident #1's room and did not provide immediate protection to Resident #1. S4 CNA responded to the incident according to the facility's policy which stated to report an incident to the nurse. Resident #1 with a diagnosis of aphasia, had limited speech, could make his needs known and his cognition was intact. Resident #1 reported he had sex with S3 CNA which was consensual. Even though there was no significant decline in Resident #1's mental 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 abused in this manner in his own home or a health care facility. S1 Administrator, S2 DON (Director of Nursing), and S5 Corporate Nurse were notified of the Immediate Jeopardy on 03/14/2025 at 6:42 p.m. The Immediate Jeopardy was removed on 03/17/2025 at 12:50 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 Abuse/Neglect Prevention Program (Revised on 09/08/2021) revealed: ABUSE/NEGLECT POLICY STATEMENT The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. INVESTIGATION: ACCIDENTS/INCIDENTS REPORTING OF ACCIDENTS/INCIDENTS: Regardless of how minor an injury may be, all accidents or incidents involving a resident, employee or visitor must be reported. Report all accidents or incidents to your immediate supervisor as soon possible. However, DO NOT leave an accident victim unattended unless it is absolutely necessary to summon assistance. All accidents/incidents must be reported to the RN (Registered Nurse) or LPN (Licensed Practical Nurse) as soon as practical (on that shift). If the accident/incident involves suspected patient abuse/neglect, or if the injury is of unknown origin, the RN or LPN must immediately report it to the Administrator and/or Director of Nursing so that facility abuse/neglect reporting and investigation procedures can be implemented. ABUSE/NEGLECT INVESTIGATION, PROTECTION AND REPORTING In the event of any evidence involving mistreatment, exploitation, neglect or abuse including injuries of an unknown source, an occurrence will be reported immediately to the Administrator or his or her designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. 1. Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his/her supervisor immediately. Further review of the Abuse/Neglect Prevention Program (Revised on 09/08/2021) failed to include immediate response by staff to protect an alleged victim of physical and psychosocial harm during and after the investigation. During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she observed S3 CNA having intercourse with Resident #1. S4 CNA further reported she immediately left out of Resident #1's room to report what she saw to the nurse, while S3 CNA and Resident #1 continued to have intercourse. During an interview on 03/13/2025 at 12:49 p.m. S5 Corporate Nurse reported S4 CNA had done the appropriate thing in immediately notifying a nurse after witnessing the 03/01/2025 incident between S3 CNA and Resident #1. S5 Corporate Nurse further reported CNAs were trained according to the facility's policy that if a CNA witnesses abuse, they are to report the abuse immediately to the nurse and the nurse would be the one to intervene. During an interview on 03/13/2025 at 1:16 p.m. S2 DON confirmed CNAs had been taught according to the facility's policy to immediately notify the nurse when an abuse incident was witnessed and the nurse would intervene. During an interview on 03/17/2025 at 2:15 p.m. S1 Administrator and S5 Corporate Nurse reported, after their review of the regulations, S4 CNA should have stayed with Resident #1 for the protection of the resident and attempt to intervene while calling for help. S1 Administrator and S5 Corporate Nurse further confirmed the facility's abuse policy did not include immediate protection for resident of alleged abuse. The facility's Plan of Removal: Resident # 1 was the resident identified as the recipient involved in the non-compliance act. All residents have the potential to be affected by this noncompliance. No other residents at the facility were noted to have been affected by this alleged non-compliance. Specific changes to the facility's abuse and neglect policy were reviewed and updated on 03-14-2025 to include: All staff are to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation. The victim of the abuse is to be examined for injuries both physical and psychological, and medically treated as indicated. Increased supervision of the alleged victim and residents may be necessary, depending on the circumstances. Room and/or staffing changes may be necessary to protect the resident from the alleged perpetrator. Staff must protect the victim from retaliation and provide emotional support and counseling to the resident during and after the investigation, as needed. Changes to this policy were in-serviced to the nursing facility staff beginning the evening of 03-14-2025 at and will continue until all staff of the facility have been in-serviced and have had a baseline compliance interview. Date and time action taken: 03-14-2025 The evening of 03-14-2025, inservice to all facility staff was initiated by the facility Administrator , DON, or ADON (Assistant Director of Nursing) on the following topic: All staff are to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation. Attempt to intervene by keeping the resident in direct line of sight and attempt to notify other staff members by hollering, pulling an emergency cord, and/or telling others to go get help. Supervisory staff are to take control of the situation once they arrive on the scene and will direct other staff members on other protection measures of the victim, including immediate removal of the accused from the situation. Administrative staff are to be notified of the abuse and neglect situation as soon as possible. The victim of the abuse is to be examined for injuries both physical and psychological, and medically treated as indicated. Increased supervision of the alleged victim and residents may be necessary, depending on the circumstances. Room and/or staffing changes may be necessary to protect the resident from the alleged perpetrator. The same staff members, along with S8 LPN, Charge Nurse, and S7 RN, Weekend Supervisor, have continued with this inservice until all facility staff have been inserviced. If the staff member was unable to be reached in person or by phone, they will be inserviced prior to starting their shift at the facility. A personnel roster has been used to ensure every employee has had the inservice. On 03-15-2025, following each staff member's inservice, a baseline competency interview has also been started. Each staff member has been interviewed by the Administrator, DON, ADON, LPN Charge Nurse, or, Weekend RN Supervisor. The specifics asked in this baseline competency interview are as follows to ensure information was learned and retained from the inservice: 1. Employee Inappropriate Sexual Encounters a. As an employee of this facility, can you have any type of sexual activity or relationship including sexual intercourse with a resident, even if it is consensual with the resident? Yes No (answer should be No) b. Sexual activity includes the following: sexual intercourse, anal intercourse, oral sex and any of other type of sexual engagement. True False (answer should be true) c. As an employee of this facility, if you witness any type of sexual activity including sexual intercourse by a staff member, are you to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation? Yes No (answer should be Yes) d. As an employee of this facility, if you witness any type of sexual activity, you must attempt to intervene by keeping the resident in direct line of sight and attempt to notify other staff members. State several ways you can do this (examples -- yell for the person to stop, yell in an attempt to get others to help, pull the call cord out of the wall for the ER light, yell from the person's doorway down the hall, etc) e. If any of the above questions are answered incorrectly, immediately stop and reinservice the employee. Explain your corrective action below. 2. Do you have any other concerns about sexual encounters at the facility that you would like to talk with administration about? Yes or No These baseline competency interviews will follow staff inservice for each staff member until all have been interviewed. If the staff member is unable to be reached in person or by phone, they will have the baseline competency interview completed prior to starting their next shift at the facility. A personnel roster has been used to ensure every employee has had the baseline competency interview. Completion date of educational inservices and baseline competency completions: 03-17-25. A QAPI (Quality Assurance Performance Improvement) monitor to assure sustained compliance will be implemented and will be completed by the Administrator, DON, ADON, LPN Charge Nurse, or Weekend RN Supervisor, by interviewing random staff members. Questions from the Post Event Sustained Monitoring Interview related to Sexual Abuse definitions and Immediate Protection of the Resident Physically and Psychologically During and After the Investigation plan of this facility will be reviewed. This will occur 3 times a week for the next 6 weeks, and then monthly thereafter until compliance is maintained to be assured that the facility staff are aware of what immediate protection of the resident during and after an abuse investigation is, and how to respond to provide this protection and appropriated interventions. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional inservices and/or corrective actions will be implemented as needed. Date of Compliance: 03-17-2025 Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 03/17/2025.

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 #1) of 3 (Resident #1, #2, and #3) residents reviewed for abuse. The facility failed to have an effective system in place to: 1. Protect Resident #1 from abuse of power by S3 Certified Nursing Assistance (CNA) when S3 CNA sexually abused Resident #1 on 03/01/2025, 2. Provide immediate protection to Resident #1, and 3. Failed to develop and implement policies to protect the resident. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. S4 CNA immediately left out of Resident #1's room and did not provide immediate protection to Resident #1. S4 CNA responded to the incident according to the facility's policy which stated to report an incident to the nurse. Resident #1 with a diagnosis of aphasia, had limited speech and his cognition was intact. Resident #1 reported having sex with S3 CNA which was consensual. Nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. S1 Administrator, S2 DON (Director of Nursing), and S5 Corporate Nurse were notified of the Immediate Jeopardy on 03/14/2025 at 6:42 p.m. The Immediate Jeopardy was removed on 03/17/2025 at 12:50 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Cross Reference F600 and F607 During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she observed S3 CNA having intercourse with Resident #1. S4 CNA further reported she immediately left out of Resident #1's room to report what she saw to the nurse, while S3 CNA and Resident #1 continued to have intercourse. Review of Abuse/Neglect Prevention Program (Revised on 09/08/2021) failed to include immediate response by staff to protect an alleged victim of physical and psychosocial harm during and after the investigation. During an interview on 03/13/2025 at 8:10 a.m. S1 Administrator reported the facility did not report the incident between Resident #1 and S3 CNA because he did not recognize it was abuse because it was consensual. During an interview on 03/13/2025 at 12:49 p.m. S5 Corporate Nurse reported S4 CNA had done the appropriate thing in immediately notifying a nurse after witnessing the 03/01/2025 incident between S3 CNA and Resident #1. S5 Corporate Nurse further reported CNAs were trained according to facility policy that if a CNA witnesses abuse, they are to report the abuse immediately to the nurse and the nurse would be the one to intervene. During an interview on 03/13/2025 at 1:16 p.m. S2 DON confirmed CNAs had been taught according to facility policy to immediately get a nurse when an abuse incident was observed and the nurse would then intervene. During an interview on 03/17/2025 at 2:15 p.m. S1 Administrator and S5 Corporate Nurse reported S1 Administrator was the designated oversight person when deficient practice occurs and was responsible for ensuring deficient practice did not occur. S1 Administrator and S5 Corporate Nurse also reported the Administrator, as the designated oversight person, was responsible for ensuring staff have been educated on the correct policy and procedure. S1 Administrator and S5 Corporate Nurse further confirmed, after their review of regulations, S4 CNA should have stayed with Resident #1 and attempted to intervene while calling for help. S1 Administrator and S5 Corporate Nurse further reported an administrative breakdown had occurred when staff had not been trained to call for help immediately and to stay with residents in an abuse situation to intervene and protect the resident. During an interview on 03/17/2025 at 2:20 p.m. S5 Corporate Nurse reported training oversight for the administrator and the administrative staff was the responsibility of the NHA (Nursing Home Administrator) Supervisor and the Chief Operating Officer. During an interview on 03/17/2025 at 2:35 p.m. S2 DON reported S4 CNA, who witnessed the 03/01/2025 incident between Resident #1 and S3 CNA, left the room while the sexual act was still in progress, and did not respond immediately to intervene and protect Resident #1. The facility's Plan of Removal: Resident # 1 was the resident identified as the recipient involved in the noncompliance. All residents have the potential to be affected by this noncompliance. No other residents at the facility were noted to have been affected by this noncompliance. On the evening of 03-14-2025, an inservice to the Administrator by NHA (Nursing Home Administrator) Supervisor, was completed. This inservice contained the following content: Nursing facility staff are entrusted with the responsibility to protect and care for the residents of the facility. Nursing facility staff are expected to recognize that engaging in a sexual relationship with a resident, even a willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. And: All staff are to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation. The victim of the abuse is to be examined for injuries both physical and psychological, and medically treated as indicated. Increased supervision of the alleged victim and residents may be necessary, depending on the circumstances. Room and/or staffing changes may be necessary to protect the resident from the alleged perpetrator. Staff must protect the victim from retaliation and provide emotional support and counseling to the resident during and after the investigation, as needed. On 03-15-25, following the Administrator's inservice, a baseline competency interview was completed. He was interviewed by the facility DON. The specifics asked in this baseline competency interview are as follows to ensure information was learned and retained from the inservice: 1. Employee Inappropriate Sexual Encounters a. As an employee of this facility, can you have any type of sexual activity or relationship including sexual intercourse with a resident, even if it is consensual with the resident? Yes No (answer should be No) b. Sexual activity includes the following: sexual intercourse, anal intercourse, oral sex and any of other type of sexual engagement. True False (answer should be true) c. As an employee of this facility, if you witness any type of sexual activity including sexual intercourse by a staff member, are you to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation? Yes No (answer should be Yes) d. As an employee of this facility, if you witness any type of sexual activity, you must attempt to intervene by keeping the resident in direct line of sight and attempt to notify other staff members. State several ways you can do this (examples -- yell for the person to stop, yell in an attempt to get others to help, pull the call cord out of the wall for the ER light, yell from the person's doorway down the hall, etc) e. If any of the above questions are answered incorrectly, immediately stop and reinservice the employee. Explain your corrective action below. 2. Do you have any other concerns about sexual encounters at the facility that you would like to talk with administration about? Yes or No Completion dates of the educational inservice and baseline competency completion for S1 Administrator: 03-14-2025 and 03-15-2025 respectively. A QAPI (Quality Assurance and Performance Improvement) monitor to assure sustained compliance of the facility staff will be implemented and will be completed the Administrator, DON, ADON (Assistant Director of Nursing), LPN (Licensed Practical Nurse) Charge Nurse, or Weekend RN (Registered Nurse) Supervisor, by interviewing random staff members. Questions from the Post Event Sustained Monitoring Interview related to Sexual Abuse definitions and Immediate Protection of the Resident Physically and Psychologically During and After the Investigation plan of this facility will be reviewed. This will occur 3 times a week for the next 6 weeks, and then monthly thereafter until compliance is maintained to be assured that the facility staff are aware of what immediate protection of the resident during and after an abuse investigation is, and how to respond to provide this protection and appropriated interventions. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional inservices and/or corrective actions will be implemented as needed. Date of Compliance: 03-17-2025 Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 03/17/2025.