**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents right to be free from sexual abuse for 2 residents (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. On 02/21/25, Resident # 1 inappropriately touched Resident # 22 and asked Resident #22 to kiss him. On 02/21/15, Resident # 1 grabbed the hand of Resident #52 and put Resident # 52's hand in his groin area. Resident # 1 then attempted to bend over and kiss Resident # 22. Resident # 1 asked Resident #52 to go to his room. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. The facility had corrected the noncompliance before the Incident investigation began on 03/31/2025. This failure placed the facility's residents at risk for abuse and neglect. Findings included: 1. Review of Resident #1's face sheet dated 03/31/2025 reflected Resident #1 was a [AGE] year-old male, with an admission date of 08/01/2023 and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors), and was discharged on 03/17/2025. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 07 indicating severe cognitive impairment, was independent in transition from sitting to standing position and walking. Review of Resident #1's care plan dated 02/15/2025 reflected Resident #1 displays inappropriate behavior of a sexual manner towards females at times. He has also asked other female residents to go back to his room with him . Monitor resident in activities as needed . Remove other residents from harm and sexual advances as needed . Remove resident from public areas if behavior is demonstrated. 2. Review of Resident #22's face sheet dated 04/02/2025 reflected she was an [AGE] year-old female, with an admission date of 01/20/2022 and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors). Review of Resident #22's MDS assessment dated [DATE] reflected Resident #22 had a BIMS score of 02 indicating severe cognitive impairment, was dependent in chair to bed transfers. Review of Resident #22's care plan dated 01/24/2022 reflected resident #22 had a diagnosis of Dementia, 09/19/2022 reflected resident #22 was unable to perform ADL functions independently. 3. Review of Resident #52's face sheet dated 04/02/2025 reflected she was a [AGE] year-old female, with an admission date of 05/31/2024 and diagnoses of encephalopathy (brain disfunction leading to symptoms such as altered mental status, memory loss), Cognitive communication deficit (impaired cognitive process). Review of Resident #52's MDS assessment dated [DATE] reflected Resident #52 had a BIMS score of 10 indicating moderate cognitive impairment and she required moderate assistance with chair to bed transfers. Review of Resident #52's care plan dated 01/28/2025 reflected she was taking psychotropic medications for depression and anxiety, had a diagnosis of dementia/Alzheimer's and was at risk for increased confusion. Review of Resident #22's progress note dated 02/21/2025 at 09:36 AM reflected LVN M heard Resident #22 yell No, do not touch me. LVN M observed Resident #1 inappropriately touching Resident #22 and asking her to kiss Resident #1. Review of Resident #52's progress note dated 02/21/2025 at 01:34 PM reflected LVN E observed Resident # 1 grab the hand of Resident #52 and said, come to my room, then attempted to bend over and kiss Resident #52. Record review of the provider investigation report reflected the Administrator completed the investigation on 03/04/2025, notified HHSC, ombudsman, medical director, police department, psych services, responsible parties of Residents #1, #22 and #52, Resident #1's medications were reviewed by the medical director, Resident #22 and Resident #52 were assessed and no emotional distress was noted, staff interviews were conducted, and Resident safe surveys were completed. Record review of the in-service training revealed 63 employees, including LVN E and LVN M, received in service on the topic Reporting abuse neglect and exploitation on 02/25/2025. Record review of the in-service training revealed 92 employees received in-service on the topic ANE reporting response on 03/31/2025. Review of Resident #1's progress note dated 03/04/2025 at 02:53 PM revealed social services had a care plan meeting with Resident #1's family member to address Resident #1's behavior issues and appropriate discharge plan, revealed a 30-day discharge notice was issued to Resident #1's family member . Review of the Q 15-minute check list revealed Resident #1 was checked every 15 minutes from 02/25/25 till 03/17/25. Record review of the physician order dated 02/26/2025 reflected Resident #1 received a new standing order for Prozac 20 mg, once a day, to address his behavior issues. Review of the Quality Assurance Committee sign in sheet revealed the facility had the committee meeting on 04/01/2025 to address the identified issue of staff did not report potential ANE to the administrator immediately. Record review of Resident #1's progress note revealed he had displayed inappropriate behaviors towards females prior to February 2025. An observation and interview with Resident #22 in the facility TV room on 03/31/2025 at 03:59 PM revealed she was sitting in her wheelchair and watching TV. Resident #22 did not remember the alleged incident which happened on 02/21/2025. Resident #22 felt safe at the facility, she was not afraid of any residents or employees. An observation and interview with Resident #52 in her room on 03/31/2025 at 04:15 PM revealed she was sitting in her wheelchair watching TV. Resident #52 stated on an unknown date Resident #1 approached her while she was sitting in her wheelchair in the 500 hallway and told her to go to Resident #1's room, Resident #1 grabbed Resident #52's hands and put her hand in Resident #1's private area. Resident #52 stated she told Resident #1 to stop, and an unknown nurse came and separated both. Resident # 52 stated this was the first such incident, she was not injured, she was not afraid of any residents, and she felt safe. Resident #52 stated Resident #1 did not stay at the same hall and he stayed in 600 hall, she did not have any similar experience from Resident #1 anymore. She stated later ADON H and the Administrator came and spoke to her and assured they were addressing the concern, and she would be safe. Interview with the Administrator on 03/31/2025 at 4:32 PM revealed she had worked at the facility for 3 years and she was the abuse coordinator. She stated she expected all the employees to report to her any suspicion of abuse immediately, all the employees had her contact information available, and all the employees were given in-service training on a regular basis on abuse/neglect. The Administrator stated two female residents, Residents #22 and #52 were inappropriately touched by Resident #1 on 02/21/2025. The Administrator said she first learned about the incident involving Resident # 52 from LVN E on 02/25/2025. As part of the investigation of that incident, she spoke with LVN M on the same day and learned about another incident involving Resident #1 inappropriately touching Resident #22. The Administrator stated both female residents were assessed and they found no injuries, discoloration, pain, or emotional distress. The Administrator stated she educated LVN M on the importance of timely notification of instances where ANE could potentially have taken place. The Administrator stated she instructed staff to complete a 15-minute check on Resident #1 until further notice, reported the alleged incident to the police, and an officer came and spoke with residents. The Administrator stated the incidents were reported to the medical director, responsible parties of each resident who were involved and to the Ombudsman. Resident #1 was referred for psych services and he received new order for medication Prozac. Safe surveys were conducted and ensured no other residents were affected and the residents felt safe and comfortable at the facility. In-service training on ANE and notification was provided to all the employees. The Administrator stated she had a care plan meeting with Resident #1's family and Resident #1 was discharged from the facility. The Administrator stated both incidents involving Residents #22 and #52 were considered as abuse, and abuse was supposed to be reported to the state within 2 hours. She stated she expected the employees to report to her the abuse incident immediately rather than waiting until 02/25/2025. She stated those were the only two incidents involving Resident #1 inappropriately behaving with residents. Interview with LVN E on 03/31/2025 at 05:10 PM revealed she observed the inappropriate behavior of Resident #1 towards Resident #52 on 02/21/2025 when Resident #52 told her about the incident. She stated she did not consider that incident as abuse since Resident #1was attempting to touch Resident #52. She stated she documented the incident in the nurses note on the same day. She stated she sent an email on 02/25/2025 to the Administrator/abuse coordinator notifying her of the alleged incident. She stated she was expected to report any suspected abuse immediately to the abuse coordinator. She stated she was not aware of any sexually inappropriate behavior by Resident #1. She stated she had received in-services on abuse regularly. She stated once she learned about the incident, she separated both residents, redirected Resident #1, and made sure Resident #52 was safe and comfortable. She stated there were several types of abuse such a physical, sexual, verbal, emotional. She stated she would also report abuse to the physician and family of the residents involved. Interview with LVN M on 04/01/2025 at 09:30 AM revealed she had worked at the facility for over two years, and she worked on the 600 hall. She stated abuse was hitting or speaking to a resident inappropriately, and there were several types of abuse such as physical, sexual, emotional. She stated she received in-service training on abuse and the most recent one was in February. She stated she would notify the DON and the Administrator/the abuse coordinator immediately of any suspected abuse/neglect. She stated not immediately reporting abuse can lead to continuation of the abusive behavior towards more residents. She stated if she observed a resident was abused, she would immediately intervene and separate them, redirect the aggressor, and make sure the victim was safe. She stated there would be interventions in place to make sure the aggressor was not repeating the behavior, he/she would be always monitored. She stated she would also report the incident to the physician and family. LVN M stated on 02/21/2025, she was working on the 600 hall nurses' station when she heard Resident #22, who was sitting in her wheelchair on the hallway, yelling don't touch me to Resident #1. She stated she saw Resident #1 touching the side of Resident #22's breast, holding, and pulling her arm, asking her to come to his room. LVN M stated she immediately separated both, took Resident #22 to her room and Resident #1 to his room, educated Resident #1 about inappropriate behaviors and boundaries. She stated she made sure Resident #1 stayed in his room, and monitored him frequently. She stated she did not report this incident to the Abuse Coordinator/the Administrator, but she reported this incident to ADON H, soon after the incident. She stated that was a suspected abuse incident and she was supposed to report it immediately to the abuse coordinator. She stated she had reported this incident she witnessed to the Administrator on 02/25/2025 when the Administrator approached her to ask about a similar incident. An interview with ADON H on 04/01/2025 at 01:34 PM revealed he had worked at the facility for 15 years and he was the supervisor for 400, 500 and 700 halls. He stated there were several types of abuse such as physical, mental, sexual, verbal, and the most recent in-service he received on abuse was yesterday. He stated Resident #1 was staying in 600 hall, and one of the nurses had made a complaint about Resident #1 inappropriately talking but they did not have any abuse incidents involving other residents. He stated he learned from the Administrator on 02/25/2025 about Resident #1 holding the hand of a female resident. He stated he was not told by any LVN about this incident. He said he received in-service on abuse and reporting abuse. He stated if an employee witnessed abuse/suspected abuse, his expectation was the employee should immediately separate the residents and made sure the residents were safe, right away call the abuse coordinator on her phone, and notify her, the physician, and family. He stated all the employees had the abuse coordinator's phone number and it was important to report the abuse to the state and have interventions in place to stop similar incidents from happening. He stated the incidents involving Resident #1 inappropriately touching Resident #22 and #52 were considered as suspected abuse and it had to be reported to the abuse coordinator immediately. Interview with CNA N on 04/02/2025 at 02:37 PM revealed she had worked at the facility for 11 years; she worked on 500 hall. She stated Resident #1 once inappropriately touched her and she reported this to the Administrator. She stated she was not aware of any other incidents where Resident #1 behaved inappropriately with female residents, other than to Resident #52 sometime in February 2025. She said she received in-service on abuse regarding this incident. She stated Resident #1 never went to other resident's rooms. She stated there were several types of abuse such as physical, sexual, verbal, financial, and she would immediately report any suspected abuse to the abuse coordinator and make sure the residents involved were safe. Observation and Interview with Resident #22 on 04/16/2025 at 11:36 AM revealed she was sitting in her wheelchair and watching TV in the common area. She appeared clean and stated she did not know Resident #1. She stated she never had any experience of inappropriate touch/behavior towards her by anybody at the facility. She stated she had no concerns about abuse. Observation and interview with Resident #52 in the dining room on 04/16/2025 at 11:49 AM revealed she was sitting in her wheelchair, ready to have her lunch. Resident #52 stated there was only one incident of an inappropriate behavior since she came to the facility, that was regarding Resident #1 touching her and asking her to come to his room. Resident #52 stated she was not aware of any similar incidents involving Resident #1, she was not afraid of any resident or employees at the facility, and she felt safe. She stated Resident #1 held her hand, asked to go to his room, then moved her hand towards his groin area, she suddenly realized his intention and moved her hand, raised her hand, and got the attention of a nurse. She stated the nurse suddenly separated Resident #1 and took her to her room. Interview with the Administrator on 04/16/2025 at 01:48 PM revealed once she learned about the sexually inappropriate behavior by Resident #1, she interviewed Resident #22 and #52, asked about the inappropriate behavior by Resident #1. The Administrator stated Resident #22 was confused and she did not remember anything about the incident. Resident #52 told the Administrator Resident #1 came to her, grabbed her hand and asked her to go to his room. Resident #52 said no, and the nurse intervened at this point and separated both residents, redirected Resident #1. The Administrator stated Resident #52 never told her about Resident #1 putting Resident #52's hand in Resident #1's groin area. The Administrator stated she was not aware of any previous sexually inappropriate incidents by Resident #1 towards other residents. She stated she had not put any interventions in place from 02/21/2025 till 02/25/2025 regarding Resident #1's behavior but LVN M monitored Resident #1 frequently. She stated once she learned about the incident on 02/25/2025, interventions were in put in place such as: notified medical director, family, 15-minute check on Resident #1, psychiatric services referral, investigated the incident and made sure there were no other similar incidents, provided in service on abuse reporting and reeducated LVN E and LVN M, discharged Resident #1 from the facility on 03/17/2025. She stated she had given verbal waning to LVN E and LVN M for not notifying the abuse coordinator immediately about the abuse incidents which happened on 02/21/2025. Interview with RN S on 04/17/2025 at 12:29 PM revealed there were several types of abuse such as physical, verbal, sexual. She stated inappropriate touch was an example of sexual abuse, and she would immediately report it to the abuse coordinator. She stated not reporting immediately would lead to more abuse incidents. She stated she received in service on abuse twice a month. She stated the only incident she knew was Resident #1 inappropriately touched staff and she did not know of any other incidents. Interview with LVN I on 04/17/2025 at 12:50 PM revealed she was working as a nurse at the facility for 2 years. She stated abuse was in different forms such as verbal, physical, emotional and it could happen between resident to resident or employee to resident. She stated an inappropriate touch was example for sexual abuse, she would immediately report to the Administrator of any abuse because delaying would lead to the abuse to continue. She stated she knew Resident #1 and heard from other staff that he inappropriately touched staff and residents. She stated she was not aware of any similar incidents; she received in service on abuse every two weeks. Interview with ADON H on 04/17/2025 at 2:17 PM revealed there were several types of abuse such as mental, physical, sexual and an example for sexual abuse was inappropriate touch. He stated if he knew about an abuse incident, he made sure the resident was safe, immediately reported to the abuse coordinator/the Administrator because it was a reportable incident to the state. He stated not notifying the abuse coordinator about abuse immediately would put resident at risk for repeated abuse incidents. He stated he received in service every two weeks, most recent one was last week, and there were no incidents of abuse at that time. He stated he learned about Resident #1's inappropriate behavior towards Resident #22 and #52 from the Administrator. Interview with CNA Q on 04/17/25 at 02:33 PM revealed she was working on the 300 hall and abuse was of several types such as sexual, emotional, physical, verbal. An example for sexual abuse was unnecessary touch of body parts, which she would let the Administrator know immediately. She stated not reporting the abuse would lead to repeat such incidents. She stated she received in services on abuse every two weeks. She stated she had one inappropriate touch incident from Resident #1, and she had reported that incident to the abuse coordinator. She stated she was not aware of any abuse incidents at that time. Interview with CNA P on 04/17/25 at 03:13 PM revealed she was working at the facility for a year. She stated abuse had several forms such as physical, verbal, sexual and inappropriate touch was sexual abuse. She stated she would immediately report to the Administrator about any abuse incident and not notifying abuse would put more residents at risk and it affected resident safety. She stated the most recent in-service on abuse was a week ago, she was not familiar with Resident #1, and she was not aware of any such abuse incidents in the facility. Interview with CNA O on 04/17/25 at 03:22 revealed she was working at the facility for 12 years. She stated abuse was of several types such as verbal, physical, sexual, neglect. She stated hitting, sexual touch were examples of abuse. She stated she received in service on abuse a week ago, she would immediately notify the Administrator of aby suspected abuse, not notifying would lead to more abuse. She stated she heard about Resident #1's sexually inappropriate behavior towards others but she had not experienced it, and she was not aware of any other such abuse incidents. Interview with RN K on 04/17/25 at 03:27 PM revealed abuse was of various types such as physical, verbal, sexual, mental. She stated inappropriate touch and comments were examples of sexual abuse. She stated she had received in-services on abuse every two weeks and she received the most recent one last week. She stated she would immediately notify the abuse coordinator whenever she learned about abuse, the risk for not notifying the Administrator about abuse would lead to continue the abuse towards more residents. She stated she was not aware of any abuse incidents at the facility. She stated she was not familiar with Resident #1; she learned from other staff about his inappropriate behavior towards females. Review of the facility's undated abuse policy titled Prohibition of abuse, neglect, and exploitation standards of practice. The Facility will ensure a safe environment for residents by prohibiting ANE. The Facility establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm . SEXUAL ABUSE: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault PREVENTION 3. Residents identified as exhibiting abusive behaviors will be assessed and appropriate interventions included in the plan of care Definition: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code §21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Sexual abuse: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of 2 (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. 1) LVN E and LVN M failed to immediately report sexual abuse incidents involving Resident #1 against Residents #22 and #52 to the Abuse Coordinator/the Administrator. 2) The facility failed to follow their policy to immediately protect Resident #22 and #52 from harm. 3) LVN E failed to identify sexual abuse when Resident #1 attempted to inappropriately touch Resident #52. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. The facility had corrected the noncompliance before the Incident investigation began on 03/31/2025. This could place residents at risk for abuse, neglect and exploitation. Findings included: Review of the undated facility policy titled PROHIBITION OF ABUSE, NEGLECT, AND EXPLOITATION (ANE) STANDARDS OF Practice revealed . STANDARDS . This Facility's abuse prohibition program includes standards and practice guidelines that address the essential components of an ANE prohibition program to include screening, training, prevention, identification, investigation, protection, reporting and response. The Facility will ensure a safe environment for residents by prohibiting ANE.The Facility establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm ABUSE: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code §21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. SEXUAL ABUSE: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault . PREVENTION . 4. Facility staff will immediately report and protect the resident if an allegation or observation of abuse has occurred . IDENTIFICATION 1. Potential ANE is identified through, but not limited to: a. Allegations of abuse / neglect or misappropriation of resident property as immediately reported to the Administrator. PROTECTION 1. Residents will be immediately protected from harm. REPORTING 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the abuse coordinator, Administrator immediately. 1. Review of Resident #1's face sheet dated 03/31/2025 reflected Resident #1 was a [AGE] year-old male, with an admission date of 08/01/2023 and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors), and was discharged on 03/17/2025. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 07 indicating severe cognitive impairment, was independent in transition from sitting to standing position and walking. Review of Resident #1's care plan dated 02/15/2025 reflected Resident #1 displays inappropriate behavior of a sexual manner towards females at times. He has also asked other female residents to go back to his room with him . Monitor resident in activities as needed . Remove other residents from harm and sexual advances as needed . Remove resident from public areas if behavior is demonstrated. 2. Review of Resident #22's face sheet dated 04/02/2025 reflected she was an [AGE] year-old female, with an admission date of 01/20/2022 and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors). Review of Resident #22's MDS assessment dated [DATE] reflected Resident #22 had a BIMS score of 02 indicating severe cognitive impairment, was dependent in chair to bed transfers. Review of Resident #22's care plan dated 01/24/2022 reflected resident #22 had a diagnosis of Dementia, 09/19/2022 reflected resident #22 was unable to perform ADL functions independently. 3. Review of Resident #52's face sheet dated 04/02/2025 reflected she was a [AGE] year-old female, with an admission date of 05/31/2024 and diagnoses of encephalopathy (brain disfunction leading to symptoms such as altered mental status, memory loss), Cognitive communication deficit (impaired cognitive process). Review of Resident #52's MDS assessment dated [DATE] reflected Resident #52 had a BIMS score of 10 indicating moderate cognitive impairment and she required moderate assistance with chair to bed transfers. Review of Resident #52's care plan dated 01/28/2025 reflected she was taking psychotropic medications for depression and anxiety, had a diagnosis of dementia/Alzheimer's and was at risk for increased confusion. Review of Resident #22's progress note dated 02/21/2025 at 09:36 AM reflected LVN M heard Resident #22 yell No, do not touch me. LVN M observed Resident #1 inappropriately touching Resident #22 and asking her to kiss Resident #1. Review of Resident #52's progress note dated 02/21/2025 at 01:34 PM reflected LVN E observed Resident # 1 grab the hand of Resident #52 and said, come to my room, then attempted to bend over and kiss Resident #52. Record review of the provider investigation report reflected the Administrator completed the investigation on 03/04/2025, notified HHSC, ombudsman, medical director, police department, psych services, responsible parties of Residents #1, #22 and #52, Resident #1's medications were reviewed by the medical director, Resident #22 and Resident #52 were assessed and no emotional distress was noted, staff interviews were conducted, and Resident safe surveys were completed. Record review of the in-service training revealed 63 employees, including LVN E and LVN M, received in service on the topic Reporting abuse neglect and exploitation on 02/25/2025. Record review of the in-service training revealed 92 employees received in-service on the topic ANE reporting response on 03/31/2025. Review of Resident #1's progress note dated 03/04/2025 at 02:53 PM revealed social services had a care plan meeting with Resident #1's family member to address Resident #1's behavior issues and appropriate discharge plan, revealed a 30-day discharge notice was issued to Resident #1's family member. Review of the Q 15-minute check list revealed Resident #1 was checked every 15 minutes from 02/25/25 till 03/17/25. Record review of the physician order dated 02/26/2025 reflected Resident #1 received a new standing order for Prozac 20 mg, once a day, to address his behavior issues. Review of the Quality Assurance Committee sign in sheet revealed the facility had the committee meeting on 04/01/2025 to address the identified issue of staff did not report potential ANE to the administrator immediately. Record review of Resident #1's progress note revealed he had displayed inappropriate behaviors towards females prior to February 2025. An observation and interview with Resident #22 in the facility TV room on 03/31/2025 at 03:59 PM revealed she was sitting in her wheelchair and watching TV. Resident #22 did not remember the alleged incident which happened on 02/21/2025. Resident #22 felt safe at the facility, she was not afraid of any residents or employees. An observation and interview with Resident #52 in her room on 03/31/2025 at 04:15 PM revealed she was sitting in her wheelchair watching TV. Resident #52 stated on an unknown date Resident #1 approached her while she was sitting in her wheelchair in the 500 hallway and told her to go to Resident #1's room, Resident #1 grabbed Resident #52's hands and put her hand in Resident #1's private area. Resident #52 stated she told Resident #1 to stop, and an unknown nurse came and separated both. Resident # 52 stated this was the first such incident, she was not injured, she was not afraid of any residents, and she felt safe. Resident #52 stated Resident #1 did not stay at the same hall and he stayed in 600 hall, she did not have any similar experience from Resident #1 anymore. She stated later ADON H and the Administrator came and spoke to her and assured they were addressing the concern, and she would be safe. Interview with the Administrator on 03/31/2025 at 4:32 PM revealed she had worked at the facility for 3 years and she was the abuse coordinator. She stated she expected all the employees to report to her any suspicion of abuse immediately, all the employees had her contact information available, and all the employees were given in-service training on a regular basis on abuse/neglect. The Administrator stated two female residents, Residents #22 and #52 were inappropriately touched by Resident #1 on 02/21/2025. The Administrator said she first learned about the incident involving Resident # 52 from LVN E on 02/25/2025. As part of the investigation of that incident, she spoke with LVN M on the same day and learned about another incident involving Resident #1 inappropriately touching Resident #22. The Administrator stated both female residents were assessed and they found no injuries, discoloration, pain, or emotional distress. The Administrator stated she educated LVN M on the importance of timely notification of instances where ANE could potentially have taken place. The Administrator stated she instructed staff to complete a 15-minute check on Resident #1 until further notice, reported the alleged incident to the police, and an officer came and spoke with residents. The Administrator stated the incidents were reported to the medical director, responsible parties of each resident who were involved and to the Ombudsman. Resident #1 was referred for psych services and he received new order for medication Prozac. Safe surveys were conducted and ensured no other residents were affected and the residents felt safe and comfortable at the facility. In-service training on ANE and notification was provided to all the employees. The Administrator stated she had a care plan meeting with Resident #1's family and Resident #1 was discharged from the facility. The Administrator stated both incidents involving Residents #22 and #52 were considered as abuse, and abuse was supposed to be reported to the state within 2 hours. She stated she expected the employees to report to her the abuse incident immediately rather than waiting until 02/25/2025. She stated those were the only two incidents involving Resident #1 inappropriately behaving with residents. Interview with LVN E on 03/31/2025 at 05:10 PM revealed she observed the inappropriate behavior of Resident #1 towards Resident #52 on 02/21/2025 when Resident #52 told her about the incident. She stated she did not consider that incident as abuse since Resident #1was attempting to touch Resident #52. She stated she documented the incident in the nurses note on the same day. She stated she sent an email on 02/25/2025 to the Administrator/abuse coordinator notifying her of the alleged incident. She stated she was expected to report any suspected abuse immediately to the abuse coordinator. She stated she was not aware of any sexually inappropriate behavior by Resident #1. She stated she had received in-services on abuse regularly. She stated once she learned about the incident, she separated both residents, redirected Resident #1, and made sure Resident #52 was safe and comfortable. She stated there were several types of abuse such a physical, sexual, verbal, emotional. She stated she would also report abuse to the physician and family of the residents involved. Interview with LVN M on 04/01/2025 at 09:30 AM revealed she had worked at the facility for over two years, and she worked on the 600 hall. She stated abuse was hitting or speaking to a resident inappropriately, and there were several types of abuse such as physical, sexual, emotional. She stated she received in-service training on abuse and the most recent one was in February. She stated she would notify the DON and the Administrator/the abuse coordinator immediately of any suspected abuse/neglect. She stated not immediately reporting abuse can lead to continuation of the abusive behavior towards more residents. She stated if she observed a resident was abused, she would immediately intervene and separate them, redirect the aggressor, and make sure the victim was safe. She stated there would be interventions in place to make sure the aggressor was not repeating the behavior, he/she would be always monitored. She stated she would also report the incident to the physician and family. LVN M stated on 02/21/2025, she was working on the 600 hall nurses' station when she heard Resident #22, who was sitting in her wheelchair on the hallway, yelling don't touch me to Resident #1. She stated she saw Resident #1 touching the side of Resident #22's breast, holding, and pulling her arm, asking her to come to his room. LVN M stated she immediately separated both, took Resident #22 to her room and Resident #1 to his room, educated Resident #1 about inappropriate behaviors and boundaries. She stated she made sure Resident #1 stayed in his room, and monitored him frequently. She stated she did not report this incident to the Abuse Coordinator/the Administrator, but she reported this incident to ADON H, soon after the incident. She stated that was a suspected abuse incident and she was supposed to report it immediately to the abuse coordinator. She stated she had reported this incident she witnessed to the Administrator on 02/25/2025 when the Administrator approached her to ask about a similar incident. An interview with ADON H on 04/01/2025 at 01:34 PM revealed he had worked at the facility for 15 years and he was the supervisor for 400, 500 and 700 halls. He stated there were several types of abuse such as physical, mental, sexual, verbal, and the most recent in-service he received on abuse was yesterday. He stated Resident #1 was staying in 600 hall, and one of the nurses had made a complaint about Resident #1 inappropriately talking but they did not have any abuse incidents involving other residents. He stated he learned from the Administrator on 02/25/2025 about Resident #1 holding the hand of a female resident. He stated he was not told by any LVN about this incident. He said he received in-service on abuse and reporting abuse. He stated if an employee witnessed abuse/suspected abuse, his expectation was the employee should immediately separate the residents and made sure the residents were safe, right away call the abuse coordinator on her phone, and notify her, the physician, and family. He stated all the employees had the abuse coordinator's phone number and it was important to report the abuse to the state and have interventions in place to stop similar incidents from happening. He stated the incidents involving Resident #1 inappropriately touching Resident #22 and #52 were considered as suspected abuse and it had to be reported to the abuse coordinator immediately. Interview with CNA N on 04/02/2025 at 02:37 PM revealed she had worked at the facility for 11 years; she worked on 500 hall. She stated Resident #1 once inappropriately touched her and she reported this to the Administrator. She stated she was not aware of any other incidents where Resident #1 behaved inappropriately with female residents, other than to Resident #52 sometime in February 2025. She said she received in-service on abuse regarding this incident. She stated Resident #1 never went to other resident's rooms. She stated there were several types of abuse such as physical, sexual, verbal, financial, and she would immediately report any suspected abuse to the abuse coordinator and make sure the residents involved were safe. Observation and Interview with Resident #22 on 04/16/2025 at 11:36 AM revealed she was sitting in her wheelchair and watching TV in the common area. She appeared clean and stated she did not know Resident #1. she stated she never had any experience of inappropriate touch/behavior towards her by anybody. She stated she had no concerns about abuse. Observation and interview with Resident #52 in the dining room on 04/16/2025 at 11:49 AM revealed she was sitting in her wheelchair, ready to have her lunch. Resident #52 stated there was only one incident of an inappropriate behavior since she came to the facility, that was regarding Resident #1 touching her and asking her to come to his room. Resident #52 stated she was not aware of any similar incidents involving Resident #1, she was not afraid of any resident or employees at the facility, and she felt safe. She stated Resident #1 held her hand, asked to go to his room, then moved her hand towards his groin area, she suddenly realized his intention and moved her hand, raised her hand, and got the attention of a nurse. She stated the nurse suddenly separated Resident #1 and took her to her room. Interview with the Administrator on 04/16/2025 at 01:48 PM revealed once she learned about the sexually inappropriate behavior by Resident #1, she interviewed Resident #22 and #52, asked about the inappropriate behavior by Resident #1. The Administrator stated Resident #22 was confused and she did not remember anything about the incident. Resident #52 told the Administrator Resident #1 came to her, grabbed her hand and asked her to go to his room. Resident #52 said no, and the nurse intervened at this point and separated both residents, redirected Resident #1. The Administrator stated Resident #52 never told her about Resident #1 putting Resident #52's hand in Resident #1's groin area. The Administrator stated she was not aware of any previous sexually inappropriate incidents by Resident #1 towards other residents. She stated she had not put any interventions in place from 02/21/2025 till 02/25/2025 regarding Resident #1's behavior but LVN M monitored Resident #1 frequently. She stated once she learned about the incident on 02/25/2025, interventions were in put in place such as: notified medical director, family, 15-minute check on Resident #1, psychiatric services referral, investigated the incident and made sure there were no other similar incidents, provided in service on abuse reporting and reeducated LVN E and LVN M, discharged Resident #1 from the facility on 03/17/2025. She stated she had given verbal waning to LVN E and LVN M for not notifying the abuse coordinator immediately about the abuse incidents which happened on 02/21/2025. Interview with RN S on 04/17/2025 at 12:29 PM revealed there were several types of abuse such as physical, verbal, sexual. She stated inappropriate touch was an example of sexual abuse, and she would immediately report it to the abuse coordinator. She stated not reporting immediately would lead to more abuse incidents. She stated she received in service on abuse twice a month. She stated the only incident she knew was Resident #1 inappropriately touched staff and she did not know of any other incidents. Interview with LVN I on 04/17/2025 at 12:50 PM revealed she was working as a nurse at the facility for 2 years. She stated abuse was in different forms such as verbal, physical, emotional and it could happen between resident to resident or employee to resident. She stated an inappropriate touch was example for sexual abuse, she would immediately report to the Administrator of any abuse because delaying would lead to the abuse to continue. She stated she knew Resident #1 and heard from other staff that he inappropriately touched staff and residents. She stated she was not aware of any similar incidents; she received in service on abuse every two weeks. Interview with ADON H on 04/17/2025 at 2:17 PM revealed there were several types of abuse such as mental, physical, sexual and an example for sexual abuse was inappropriate touch. He stated if he knew about an abuse incident, he made sure the resident was safe, immediately reported to the abuse coordinator/the Administrator because it was a reportable incident to the state. He stated not notifying the abuse coordinator about abuse immediately would put resident at risk for repeated abuse incidents. He stated he received in service every two weeks, most recent one was last week, and there were no incidents of abuse at that time. He stated he learned about Resident #1's inappropriate behavior towards Resident #22 and #52 from the Administrator. Interview with CNA Q on 04/17/25 at 02:33 PM revealed she was working on the 300 hall and abuse was of several types such as sexual, emotional, physical, verbal. An example for sexual abuse was unnecessary touch of body parts, which she would let the Administrator know immediately. She stated not reporting the abuse would lead to repeat such incidents. She stated she received in services on abuse every two weeks. She stated she had one inappropriate touch incident from Resident #1, and she had reported that incident to the abuse coordinator. She stated she was not aware of any abuse incidents at that time. Interview with CNA P on 04/17/25 at 03:13 PM revealed she was working at the facility for a year. She stated abuse had several forms such as physical, verbal, sexual and inappropriate touch was sexual abuse. She stated she would immediately report to the Administrator about any abuse incident and not notifying abuse would put more residents at risk and it affected resident safety. She stated the most recent in-service on abuse was a week ago, she was not familiar with Resident #1, and she was not aware of any such abuse incidents in the facility. Interview with CNA O on 04/17/25 at 03:22 revealed she was working at the facility for 12 years. She stated abuse was of several types such as verbal, physical, sexual, neglect. She stated hitting, sexual touch were examples of abuse. She stated she received in service on abuse a week ago, she would immediately notify the Administrator of aby suspected abuse, not notifying would lead to more abuse. She stated she heard about Resident #1's sexually inappropriate behavior towards others but she had not experienced it, and she was not aware of any other such abuse incidents. Interview with RN K on 04/17/25 at 03:27 PM revealed abuse was of various types such as physical, verbal, sexual, mental. She stated inappropriate touch and comments were examples of sexual abuse. She stated she had received in-services on abuse every two weeks and she received the most recent one last week. She stated she would immediately notify the abuse coordinator whenever she learned about abuse, the risk for not notifying the Administrator about abuse would lead to continue the abuse towards more residents. She stated she was not aware of any abuse incidents at the facility. She stated she was not familiar with Resident #1; she learned from other staff about his inappropriate behavior towards females.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse, to the Administrator of the facility and the State Survey Agency for two (Residents #22 and #52) of 24 residents reviewed for abuse and neglect. LVN E and LVN M failed to immediately report the sexual abuse incidents involving Residents #22 and #52 to the Administrator. LVN M observed an incident of suspected sexual abuse involving Resident #1 and Resident #22 on 02/21/2025 at 09:36 AM and LVN E observed another incident of suspected sexual abuse involving Resident #1 and Resident #52 on 02/21/2025 at 01:34 PM. The administrator learned about these incidents on 02/25/2025 and she self-reported the allegation of sexual abuse to the state agency on 02/25/2025 at 04:00 PM. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. The facility had corrected the noncompliance before the Incident investigation began on 03/31/2025. This failure could place residents at risk of abuse and neglect. Findings included: 1. Review of Resident #1's face sheet dated 03/31/2025 reflected Resident #1 was a [AGE] year-old male, with an admission date of 08/01/2023 and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors), and was discharged on 03/17/2025. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 07 indicating severe cognitive impairment, was independent in transition from sitting to standing position and walking. Review of Resident #1's care plan dated 02/15/2025 reflected Resident #1 displays inappropriate behavior of a sexual manner towards females at times. He has also asked other female residents to go back to his room with him . Monitor resident in activities as needed . Remove other residents from harm and sexual advances as needed . Remove resident from public areas if behavior is demonstrated. 2. Review of Resident #22's face sheet dated 04/02/2025 reflected she was an [AGE] year-old female, with an admission date of 01/20/2022 and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors). Review of Resident #22's MDS assessment dated [DATE] reflected Resident #22 had a BIMS score of 02 indicating severe cognitive impairment, was dependent in chair to bed transfers. Review of Resident #22's care plan dated 01/24/2022 reflected resident #22 had a diagnosis of Dementia, 09/19/2022 reflected resident #22 was unable to perform ADL functions independently. 3. Review of Resident #52's face sheet dated 04/02/2025 reflected she was a [AGE] year-old female, with an admission date of 05/31/2024 and diagnoses of encephalopathy (brain disfunction leading to symptoms such as altered mental status, memory loss), Cognitive communication deficit (impaired cognitive process). Review of Resident #52's MDS assessment dated [DATE] reflected Resident #52 had a BIMS score of 10 indicating moderate cognitive impairment and she required moderate assistance with chair to bed transfers. Review of Resident #52's care plan dated 01/28/2025 reflected she was taking psychotropic medications for depression and anxiety, had a diagnosis of dementia/Alzheimer's and was at risk for increased confusion. Review of Resident #22's progress note dated 02/21/2025 at 09:36 AM reflected LVN M heard Resident #22 yell No, do not touch me. LVN M observed Resident #1 inappropriately touching Resident #22 and asking her to kiss Resident #1. Review of Resident #52's progress note dated 02/21/2025 at 01:34 PM reflected LVN E observed Resident # 1 grab the hand of Resident #52 and said, come to my room, then attempted to bend over and kiss Resident #52. Record review of the provider investigation report reflected the Administrator completed the investigation on 03/04/2025, notified HHSC, ombudsman, medical director, police department, psych services, responsible parties of Residents #1, #22 and #52, Resident #1's medications were reviewed by the medical director, Resident #22 and Resident #52 were assessed and no emotional distress was noted, staff interviews were conducted, and Resident safe surveys were completed. Record review of the in-service training revealed 63 employees, including LVN E and LVN M, received in service on the topic Reporting abuse neglect and exploitation on 02/25/2025. Record review of the in-service training revealed 92 employees received in-service on the topic ANE reporting response on 03/31/2025. Review of Resident #1's progress note dated 03/04/2025 at 02:53 PM revealed social services had a care plan meeting with Resident #1's family member to address Resident #1's behavior issues and appropriate discharge plan, revealed a 30-day discharge notice was issued to Resident #1's family member . Review of the Q 15-minute check list revealed Resident #1 was checked every 15 minutes from 02/25/25 till 03/17/25. Record review of the physician order dated 02/26/2025 reflected Resident #1 received a new standing order for Prozac 20 mg, once a day, to address his behavior issues. Review of the Quality Assurance Committee sign in sheet revealed the facility had the committee meeting on 04/01/2025 to address the identified issue of staff did not report potential ANE to the administrator immediately. Record review of Resident #1's progress note revealed he had displayed inappropriate behaviors towards females prior to February 2025. An observation and interview with Resident #22 in the facility TV room on 03/31/2025 at 03:59 PM revealed she was sitting in her wheelchair and watching TV. Resident #22 did not remember the alleged incident which happened on 02/21/2025. Resident #22 felt safe at the facility, she was not afraid of any residents or employees. An observation and interview with Resident #52 in her room on 03/31/2025 at 04:15 PM revealed she was sitting in her wheelchair watching TV. Resident #52 stated on an unknown date Resident #1 approached her while she was sitting in her wheelchair in the 500 hallway and told her to go to Resident #1's room, Resident #1 grabbed Resident #52's hands and put her hand in Resident #1's private area. Resident #52 stated she told Resident #1 to stop, and an unknown nurse came and separated both. Resident # 52 stated this was the first such incident, she was not injured, she was not afraid of any residents, and she felt safe. Resident #52 stated Resident #1 did not stay at the same hall and he stayed in 600 hall, she did not have any similar experience from Resident #1 anymore. She stated later ADON H and the Administrator came and spoke to her and assured they were addressing the concern, and she would be safe. Interview with the Administrator on 03/31/2025 at 4:32 PM revealed she had worked at the facility for 3 years and she was the abuse coordinator. She stated she expected all the employees to report to her any suspicion of abuse immediately, all the employees had her contact information available, and all the employees were given in-service training on a regular basis on abuse/neglect. The Administrator stated two female residents, Residents #22 and #52 were inappropriately touched by Resident #1 on 02/21/2025. The Administrator said she first learned about the incident involving Resident # 52 from LVN E on 02/25/2025. As part of the investigation of that incident, she spoke with LVN M on the same day and learned about another incident involving Resident #1 inappropriately touching Resident #22. The Administrator stated both female residents were assessed and they found no injuries, discoloration, pain, or emotional distress. The Administrator stated she educated LVN M on the importance of timely notification of instances where ANE could potentially have taken place. The Administrator stated she instructed staff to complete a 15-minute check on Resident #1 until further notice, reported the alleged incident to the police, and an officer came and spoke with residents. The Administrator stated the incidents were reported to the medical director, responsible parties of each resident who were involved and to the Ombudsman. Resident #1 was referred for psych services and he received new order for medication Prozac. Safe surveys were conducted and ensured no other residents were affected and the residents felt safe and comfortable at the facility. In-service training on ANE and notification was provided to all the employees. The Administrator stated she had a care plan meeting with Resident #1's family and Resident #1 was discharged from the facility. The Administrator stated both incidents involving Residents #22 and #52 were considered as abuse, and abuse was supposed to be reported to the state within 2 hours. She stated she expected the employees to report to her the abuse incident immediately rather than waiting until 02/25/2025. She stated those were the only two incidents involving Resident #1 inappropriately behaving with residents. Interview with LVN E on 03/31/2025 at 05:10 PM revealed she observed the inappropriate behavior of Resident #1 towards Resident #52 on 02/21/2025 when Resident #52 told her about the incident. She stated she did not consider that incident as abuse since Resident #1was attempting to touch Resident #52. She stated she documented the incident in the nurses note on the same day. She stated she sent an email on 02/25/2025 to the Administrator/abuse coordinator notifying her of the alleged incident. She stated she was expected to report any suspected abuse immediately to the abuse coordinator. She stated she was not aware of any sexually inappropriate behavior by Resident #1. She stated she had received in-services on abuse regularly. She stated once she learned about the incident, she separated both residents, redirected Resident #1, and made sure Resident #52 was safe and comfortable. She stated there were several types of abuse such a physical, sexual, verbal, emotional. She stated she would also report abuse to the physician and family of the residents involved. Interview with LVN M on 04/01/2025 at 09:30 AM revealed she had worked at the facility for over two years, and she worked on the 600 hall. She stated abuse was hitting or speaking to a resident inappropriately, and there were several types of abuse such as physical, sexual, emotional. She stated she received in-service training on abuse and the most recent one was in February. She stated she would notify the DON and the Administrator/the abuse coordinator immediately of any suspected abuse/neglect. She stated not immediately reporting abuse can lead to continuation of the abusive behavior towards more residents. She stated if she observed a resident was abused, she would immediately intervene and separate them, redirect the aggressor, and make sure the victim was safe. She stated there would be interventions in place to make sure the aggressor was not repeating the behavior, he/she would be always monitored. She stated she would also report the incident to the physician and family. LVN M stated on 02/21/2025, she was working on the 600 hall nurses' station when she heard Resident #22, who was sitting in her wheelchair on the hallway, yelling don't touch me to Resident #1. She stated she saw Resident #1 touching the side of Resident #22's breast, holding, and pulling her arm, asking her to come to his room. LVN M stated she immediately separated both, took Resident #22 to her room and Resident #1 to his room, educated Resident #1 about inappropriate behaviors and boundaries. She stated she made sure Resident #1 stayed in his room, and monitored him frequently. She stated she did not report this incident to the Abuse Coordinator/the Administrator, but she reported this incident to ADON H, soon after the incident. She stated that was a suspected abuse incident and she was supposed to report it immediately to the abuse coordinator. She stated she had reported this incident she witnessed to the Administrator on 02/25/2025 when the Administrator approached her to ask about a similar incident. An interview with ADON H on 04/01/2025 at 01:34 PM revealed he had worked at the facility for 15 years and he was the supervisor for 400, 500 and 700 halls. He stated there were several types of abuse such as physical, mental, sexual, verbal, and the most recent in-service he received on abuse was yesterday. He stated Resident #1 was staying in 600 hall, and one of the nurses had made a complaint about Resident #1 inappropriately talking but they did not have any abuse incidents involving other residents. He stated he learned from the Administrator on 02/25/2025 about Resident #1 holding the hand of a female resident. He stated he was not told by any LVN about this incident. He said he received in-service on abuse and reporting abuse. He stated if an employee witnessed abuse/suspected abuse, his expectation was the employee should immediately separate the residents and made sure the residents were safe, right away call the abuse coordinator on her phone, and notify her, the physician, and family. He stated all the employees had the abuse coordinator's phone number and it was important to report the abuse to the state and have interventions in place to stop similar incidents from happening. He stated the incidents involving Resident #1 inappropriately touching Resident #22 and #52 were considered as suspected abuse and it had to be reported to the abuse coordinator immediately. Interview with CNA N on 04/02/2025 at 02:37 PM revealed she had worked at the facility for 11 years; she worked on 500 hall. She stated Resident #1 once inappropriately touched her and she reported this to the Administrator. She stated she was not aware of any other incidents where Resident #1 behaved inappropriately with female residents, other than to Resident #52 sometime in February 2025. She said she received in-service on abuse regarding this incident. She stated Resident #1 never went to other resident's rooms. She stated there were several types of abuse such as physical, sexual, verbal, financial, and she would immediately report any suspected abuse to the abuse coordinator and make sure the residents involved were safe. Observation and Interview with Resident #22 on 04/16/2025 at 11:36 AM revealed she was sitting in her wheelchair and watching TV in the common area. She appeared clean and stated she did not know Resident #1. she stated she never had any experience of inappropriate touch/behavior towards her by anybody. She stated she had no concerns about abuse. Observation and interview with Resident #52 in the dining room on 04/16/2025 at 11:49 AM revealed she was sitting in her wheelchair, ready to have her lunch. Resident #52 stated there was only one incident of an inappropriate behavior since she came to the facility, that was regarding Resident #1 touching her and asking her to come to his room. Resident #52 stated she was not aware of any similar incidents involving Resident #1, she was not afraid of any resident or employees at the facility, and she felt safe. She stated Resident #1 held her hand, asked to go to his room, then moved her hand towards his groin area, she suddenly realized his intention and moved her hand, raised her hand, and got the attention of a nurse. She stated the nurse suddenly separated Resident #1 and took her to her room. Interview with the Administrator on 04/16/2025 at 01:48 PM revealed once she learned about the sexually inappropriate behavior by Resident #1, she interviewed Resident #22 and #52, asked about the inappropriate behavior by Resident #1. The Administrator stated Resident #22 was confused and she did not remember anything about the incident. Resident #52 told the Administrator Resident #1 came to her, grabbed her hand and asked her to go to his room. Resident #52 said no, and the nurse intervened at this point and separated both residents, redirected Resident #1. The Administrator stated Resident #52 never told her about Resident #1 putting Resident #52's hand in Resident #1's groin area. The Administrator stated she was not aware of any previous sexually inappropriate incidents by Resident #1 towards other residents. She stated she had not put any interventions in place from 02/21/2025 till 02/25/2025 regarding Resident #1's behavior but LVN M monitored Resident #1 frequently. She stated once she learned about the incident on 02/25/2025, interventions were in put in place such as: notified medical director, family, 15-minute check on Resident #1, psychiatric services referral, investigated the incident and made sure there were no other similar incidents, provided in service on abuse reporting and reeducated LVN E and LVN M, discharged Resident #1 from the facility on 03/17/2025. She stated she had given verbal waning to LVN E and LVN M for not notifying the abuse coordinator immediately about the abuse incidents which happened on 02/21/2025. Interview with RN S on 04/17/2025 at 12:29 PM revealed there were several types of abuse such as physical, verbal, sexual. She stated inappropriate touch was an example of sexual abuse, and she would immediately report it to the abuse coordinator. She stated not reporting immediately would lead to more abuse incidents. She stated she received in service on abuse twice a month. She stated the only incident she knew was Resident #1 inappropriately touched staff and she did not know of any other incidents. Interview with LVN I on 04/17/2025 at 12:50 PM revealed she was working as a nurse at the facility for 2 years. She stated abuse was in different forms such as verbal, physical, emotional and it could happen between resident to resident or employee to resident. She stated an inappropriate touch was example for sexual abuse, she would immediately report to the Administrator of any abuse because delaying would lead to the abuse to continue. She stated she knew Resident #1 and heard from other staff that he inappropriately touched staff and residents. She stated she was not aware of any similar incidents; she received in service on abuse every two weeks. Interview with ADON H on 04/17/2025 at 2:17 PM revealed there were several types of abuse such as mental, physical, sexual and an example for sexual abuse was inappropriate touch. He stated if he knew about an abuse incident, he made sure the resident was safe, immediately reported to the abuse coordinator/the Administrator because it was a reportable incident to the state. He stated not notifying the abuse coordinator about abuse immediately would put resident at risk for repeated abuse incidents. He stated he received in service every two weeks, most recent one was last week, and there were no incidents of abuse at that time. He stated he learned about Resident #1's inappropriate behavior towards Resident #22 and #52 from the Administrator. Interview with CNA Q on 04/17/25 at 02:33 PM revealed she was working on the 300 hall and abuse was of several types such as sexual, emotional, physical, verbal. An example for sexual abuse was unnecessary touch of body parts, which she would let the Administrator know immediately. She stated not reporting the abuse would lead to repeat such incidents. She stated she received in services on abuse every two weeks. She stated she had one inappropriate touch incident from Resident #1, and she had reported that incident to the abuse coordinator. She stated she was not aware of any abuse incidents at that time. Interview with CNA P on 04/17/25 at 03:13 PM revealed she was working at the facility for a year. She stated abuse had several forms such as physical, verbal, sexual and inappropriate touch was sexual abuse. She stated she would immediately report to the Administrator about any abuse incident and not notifying abuse would put more residents at risk and it affected resident safety. She stated the most recent in-service on abuse was a week ago, she was not familiar with Resident #1, and she was not aware of any such abuse incidents in the facility. Interview with CNA O on 04/17/25 at 03:22 revealed she was working at the facility for 12 years. She stated abuse was of several types such as verbal, physical, sexual, neglect. She stated hitting, sexual touch were examples of abuse. She stated she received in service on abuse a week ago, she would immediately notify the Administrator of aby suspected abuse, not notifying would lead to more abuse. She stated she heard about Resident #1's sexually inappropriate behavior towards others but she had not experienced it, and she was not aware of any other such abuse incidents. Interview with RN K on 04/17/25 at 03:27 PM revealed abuse was of various types such as physical, verbal, sexual, mental. She stated inappropriate touch and comments were examples of sexual abuse. She stated she had received in-services on abuse every two weeks and she received the most recent one last week. She stated she would immediately notify the abuse coordinator whenever she learned about abuse, the risk for not notifying the Administrator about abuse would lead to continue the abuse towards more residents. She stated she was not aware of any abuse incidents at the facility. She stated she was not familiar with Resident #1; she learned from other staff about his inappropriate behavior towards females. Review of the facility undated abuse policy titled Prohibition of abuse, neglect, and exploitation standards of practice revealed The Facility will ensure a safe environment for residents by prohibiting ANE. The Facility establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm. The Facility has designated a person or persons responsible for coordinating and monitoring the ANE prohibition program. This person is the Administrator. Definition: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code §21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Sexual abuse: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault. REPORTING:1. Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property, shall report the incident to the abuse coordinator, Administrator immediately. 2.Any supervisor of an employee or any employee without a supervisor present at the time of the allegation will report the allegation directly to the Administrator immediately. 3. Failure to do so will result in disciplinary action, up to and including termination. 4.The Facility will report allegations to the state agency in accordance with state law.