Health inspection·August 16, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few noted.Record review of Resident #1's social services notes, dated 08/14/2025 at 1:13 p.m., indicated social services was notified of an alleged incident of non-consensual sexual contact between Resident #1 and Resident #2. Upon interview, Resident #1 stated she was seated on her bed when fellow Resident #2, alleged perpetrator, entered her room sat beside her and placed his hands inside her brief despite her telling him to stop. She denied any vaginal penetration and expressed that she did not consent to the contact she reported feeling upset and surprised as she previously considered him Resident #2 a friend. Social services provided emotional support validated Resident #1's feelings and assured her that steps were being taken to ensure her safety. Resident #1 was informed that Resident #2 would be relocated and instructed her to notify staff immediately if he approaches her. Resident #1 verbalized understanding and agreed to report any further concerns. Social services coordinated with nursing, administration and the investigation team to ensure separation of residents. Witnesses' interviews, completion of body skin assessment and initiation of the formal investigation. Ongoing emotional support and monitoring will be provided.Record review of Resident #1's social services notes, dated 08/14/2025 at 1:40 p.m., indicated Resident #1 carries a diagnosis of dementia which impacts her judgement, impulse control and reliability of self-reported information due to her cognitive impairment, statements made by Resident #1 cannot be considered fully reliable without corroborating information. Social services will continue to monitor Resident #1 for safety, provide redirection as needed and collaborate with nursing and the interdisciplinary team to address ongoing behavioral concerns.Record review of Resident #1's social services notes, dated 08/15/2025 at 10:02 a.m., indicated social services met with Resident #1 to review and have her sign the grievance filed regarding the incident with another resident on 8/14/2025. The grievance and actions taken were explained to her and she expressed that she was pleased with how the matter was addressed Resident #1 was observed to be in good spirits when asked about her well-being following the incident she stated that she was fine. Upon inquiry regarding her relationship with Resident #2, Resident #1 denied being in a relationship she indicated that he had been pursuing her, but she reiterated she denies any desires only friendship. She stated one time before, me and the lady up the road went downstairs and when we came back he was laying in the other bed in my room. This statement demonstrates cognitive impairment as there is no downstairs or lady up the road and she has never had passes outside the facility. Resident #1 was engaged in conversation, understood the discussion regarding the grievance and continued to demonstrate cooperative and appropriate behavior throughout the interaction. Plan continue to monitor interactions with other residents, provide ongoing emotional support and education regarding boundaries and appropriate sexual behavior as needed.2. Record review of Resident #2's face sheet, dated 08/16/2025, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included insomnia due to mental disorder (inability to fall asleep), adjustment disorder with anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Major Depressive Disorder with severe psychotic symptoms (a severe form of depression where a person experiences symptoms of psychosis, such as hallucinations or delusions, often reflecting depressive themes of worthlessness or guilt). discharge date [DATE] at 6:34 p.m. to psychiatric hospital.Record review of Resident #2's quarterly MDS assessment, dated 05/06/2025, indicated he made himself understood and understood others. He had severe cognitive impairment, identified with a BIMS score of 06. He required partial/moderate assist with toileting, personal hygiene and bathing.Record review of Resident #2's care plan, dated 08/14/2025, indicated Resident #2 had potential sexually inappropriate with a resident related to impaired judgement. Intervention was admission to behavioral hospital for evaluation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675172 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and admission. Place on 1:1 care until transported to behavioral hospital.Record review of Resident #2's facility incident report, dated 08/14/2025 at 12:08 p.m., the Resident description section read in part .when asked Resident #2 about the incident resident stated we are both grown adults, so it is not abnormal for two grown adults to enjoy these types of things, we were both enjoying it. Nursing description section read in part: Resident #2 noted in his wheelchair in another resident's room at her (Resident #1) bedside with his hands in her (Resident #1) brief digitally penetrating the resident (Resident #1). Immediate action taken section read in part: . Resident #2 removed from resident's (Resident #1) room and educated on resident-to-resident incidents, head to toe assessment as well as pain assessment completed no abnormal abnormalities noted. Social worker and psychology counselor made aware nurse practitioner and RP notified. Local Police Department notified 8/14/2025 at 1:23 p.m.Record review of Resident #2's progress notes, dated 08/14/2025 at 12:33 p.m., ( authored by LVN A) indicated Resident was in a female room resident (Resident #2) was sitting in his wheelchair with his fingers inside of the female (Resident #1) vagina going in and out of her vagina with his fingers another resident (Resident #3) was coming down the hall to see what the resident was doing and he called the staff to come down there. This nurse entered the room the female resident (Resident #1) was lying on the bed and the male resident (Resident #2) had his fingers in her vagina I told the resident (Resident #2) he can't be doing that he stated I don't see why not it's nothing wrong with that. This nurse escorted the resident (Resident #2) out the room this nurse and ADON and CNA interviewed the female resident (Resident #1) to ask her did she give the resident (Resident #2) permission to do that to her, she stated no she wanted him (Resident #2) to stop she (Resident #1) asked him (Resident #2) twice to stop and he (Resident #2) kept going and told her, she was going to like it. Notified DON, social worker, administrator and RP. Record review of Resident #2's progress note, dated 08/14/2025 at 12:36 p.m. and authored by ADON, indicated NP made aware of incident and gave the ok to send resident (Resident #2) out to the behavioral hospital.Record review of Resident #2's social services note, dated 08/14/2025, indicated interview investigation completed by social services Resident #2 acknowledged physical contact occurred describing it as consensual and mutually enjoyable. He (Resident #2) stated Resident #1 laid her head back and appeared to enjoy it and denied being told to stop he (Resident #2) expressed that if she (Resident #1) had told him to stop he would have done so immediately. Social services notes Resident #2 demonstrates lapses in memory which may impact the accuracy and consistency of his statements due to these cognitive limitations self-reported information should be interpreted with caution and corroborated with additional sources when possible. Social services will continue to monitor cognitive status collaborate with nursing and therapy staff and provide supportive interventions as appropriate.Record review of Resident #2's progress note, dated 08/14/2025 at 3:35 p.m. and authored by DON, indicated Resident #2 currently isolated on one to one sitting until behavior hospital is here to transport.3. Record review of Resident #3's face sheet, dated 08/16/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #3 had diagnoses which included insomnia (inability to fall asleep), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Major Depressive Disorder (a severe form of depression where a person experiences symptoms of reflecting depressive themes of worthlessness or guilt).Record review of Resident #3's quarterly MDS assessment, dated 07/17/2025, indicated he made himself understood and understood others. He had no cognitive impairment, identified with a BIMS score of 15. He required partial/moderate assist with toileting, personal hygiene and bathing.Record review of the facility's PIR (Provider Investigation Report), report to HHSC, dated 08/14/2025, incident category as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675172 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few abuse, Resident #2 with his hand touching Resident #1 in her brief, confirmed and signed by the Administrator. PIR indicated the incident occurred on 08/14/2025 at 12:08 p.m. in Resident #1 room.During an interview on 08/15/2025 at 2:00 p.m. with Resident #3 said he was the one who reported and saw what had happened to Resident #1. Resident #3 said he was rolling down the hall in his wheelchair around noon yesterday (08/14/2025) headed to the dining room for lunch. Resident #3 said he was looking from side to side both ways in rooms and when he got to Resident #1's room he saw Resident #2 pushing his fingers, going in and out of Resident #1's vagina area. Resident #3 said Resident #1 had no underwear on and Resident #2 was holding one leg of Resident #1 with his right hand and using his left hand going in and out of Resident #1's vagina. Resident #3 said he was angry because that could have been his mom or his grandmother. Resident #3 said he started yelling help help stop. Resident #3 said it looked like Resident #1 couldn't move and thought Resident #1 was saying no. Resident #3 said Resident #2 had a smile on his face that looked like an evil laugh. Resident #3 said LVN A arrived, got resident #2 by the wheelchair and took him completely off the hall. Resident #3 said he didn't know what happened after that, but he thought Resident #2 went to a behavior hospital because he hadn't seen him again since then. Resident #3 said Resident #2 usually sat out on the front porch and fed the birds. Resident #3 said he had no concerns of anyone harming him and if someone were too, he'd report it to the Administrator.During an observation and interview on 08/15/2025 at 2:00 p.m., Resident #1 she was sitting on the edge of her bed and said, it all went crazy as far as she was concerned, and she was ok with it. Resident #1 said Resident #2 tried but didn't get into her pants because her dad was a police officer and she knew how to handle men like that. Resident #1 said when Resident #2 stopped touching her vagina she asked him to start again because she did not want him to hurt that young girl. Resident #1 said the young girl was around the age of 12-[AGE] years old. She said Resident #2 only wanted to touch my body because it was so soft and so good. She said she was pregnant and did not want to mess her body up, so she just let Resident #2 touch her legs. Resident #1 stated she felt safe living at the facility and Resident #2 was a friend who was not dangerous. Resident #1 said if she was in danger or hurt she would report it to the office. Resident #1 said there were no witnesses to the incident because no one was on the porch.During an interview on 08/15/2025 at 09:30 a.m., the Administrator said he was the abuse coordinator and was responsible for investigating the incident that occurred yesterday (08/14/2025) between Resident #1 and Resident #2. The Administrator said Resident #2 was not in the facility and was sent to a behavioral hospital the same day of the incident. The Administrator said Residents #1 and #2 were not a couple or in a romantic relationship. The Administrator said Resident #2 liked to go outside and feed the birds and was often seen alone. The Administrator said Resident #3 witnessed the incident and alerted nursing staff and nursing staff immediately separated the two residents. Resident #2 was immediately taken to another hall for 1:1 and interviewed and cleaned up. The Administrator said Resident #2 was seen with his fingers inside of Resident #1's vagina by LVN A and CNA B. The Administrator said when Resident #1 was initially interviewed right after the incident she said she told Resident #2 no, and Resident #2 said Resident #1 did not tell him no or to stop so he thought she was enjoying it. The Administrator said the incident had been reported to the police and they had taken written statements from Residents #1, #2, #3 and LVN A, CNA B and ADON. The Administrator said he started the investigation and reported it to HHSC.During an interview on 08/15/2025 at 5:10 p.m., CNA B said she was also the CNA Supervisor which was like a lead CNA. CNA B said around 12 noon, on 8/14/2025, she was in the dining room passing trays and heard Resident #3 yelling for help. CNA B said when she got to Resident #1's room she saw Resident #1 lying on the bed with her head to the foot of the bed, legs opened and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675172 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #2 was in his wheelchair between Resident # 1's legs, his right hand on his wheelchair arm, his left hand was twisting inside of Resident #1's vagina. CNA B said Resident #1 looked scared, holding her teddy bear on her chest. CNA B said Resident #1 said she didn't want Resident #2 there. CNA B said this was her first time seeing Resident #2 do something like this and she had never seen Resident #2 naked but he liked to sleep naked. CNA B said she was shocked, Resident #2 was not perverted. CNA B said she saw Residents #1 and #2 talking before in the front foyer, but nothing sexual or romantic with each other or with any other female. CNA B said Resident #2 said he just wanted to make Resident #1 feel good because he knew he would feel good. CNA B said Resident #2 said Resident #1 didn't say he couldn't do it. CNA B said she didn't think Resident #2 knew Resident #1 was confused. CNA B said she and LVN A were the first to show up and that LVN A told Resident #2 to stop and he stopped. LVN A took Resident #2 out of Resident #1's room. CNA B said she really thought Resident #2 didn't think he was doing anything wrong; he was not confused and had his right mind. CNA B said she thought Resident #2 didn't know Resident #1 didn't want him to touch her vaginal area. CNA B said CNA C sat with Resident #2 until CNA D arrived to relieve him. CNA B said after LVN A removed Resident #2 from the room and interviewed Resident #1, she continued with her assignments she didn't know what happened after that. CNA B said she was in-serviced on abuse and neglect and on how to recognize consensual versus non-consensual touching and to report immediately to the Administrator who was the abuse coordinator.During an interview on 08/15/2025 at 5:10 p.m., CNA C said he worked the 2p-10p shift and sat 1:1 with Resident #2 from 2:30 p.m. to about 3:30 p.m. when CNA D arrived and took over the 1:1 until Resident #2 left the building. CNA C said Resident #2 was agitated because he couldn't go back to his hall. CNA C said he and Resident #2 were on hall 100. CNA C said he never worked with Resident #2 before, and Resident #2 kept saying I didn't do anything wrong. CNA C said Resident #2 said he felt like he was being prosecuted because he couldn't go to his room. CNA C said Resident #2 was usually quiet and not get into arguments. CNA C said CNA A instructed him to do 1:1 because of the incident and they were keeping Residents' #1 and #2 separated. CNA C said he washed the resident's hands. CNA C said he did not see the female resident. CNA C said he did not do any documentation because he only had him for an hour to 45 minutes and the Resident didn't go anywhere or do anything. CNA C said he was trained on abuse and neglect, to report immediately to the abuse coordinator who was the Administrator and how to identify signs and symptoms of inappropriate sexual behaviors such as crying, saying no or moving away and what it looks like when someone is consenting versus not consenting to sexual activity such as kissing back or touching back. CNA C said he would report all sexual behavior inappropriate and consenting and non-consenting to the DON and Administrator.During an interview on 08/15/2025 at 5:50 p.m., CNA D said she got to the facility about 3:00 p.m., because CNA B called and asked if she could sit 1:1 with Resident #2. CNA D said when she got to the facility around 3:00 p.m. CNA B told her it was for allegations of inappropriate behavior with Resident #2. CNA D said she didn't document anything because she stayed with Resident #2 the whole time on hall 100 because the residents were to be kept apart until he was transferred to a behavior hospital. CNA D said Resident #2 would say I did not do anything wrong. CNA D said she provided care for Resident #2 before, and she never saw him make any sexual advances towards Resident #1 or towards any other female resident. CNA D said she didn't think they were a couple because she never saw them together and Resident #1 needed constant redirection to where her room was because she had some confusion. CNA D said Resident #2 had very good understanding, but had said he and Resident #1 were in a relationship for a couple of months and in his mind he thought they were in a relationship. CNA D said she didn't think Resident #2 was a danger to anyone else. CNA D said she was in-serviced on and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675172 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few verbalized knowledge of abuse and neglect, resident to resident abuse, sexual encounters and how to recognize consensual and non-consensual sexual advances. CNA D said Resident #2 didn't understand why he had to leave but she overheard the Social Worker explaining to Resident #2 about it being protocol and precautions for both the resident's safety.During an interview on 08/16/2025 at 10:00 a.m., LVN A said Resident #3 alerted him to come to Resident #1's room and when she got to Resident #1's door, it was wide open, and she could see Resident #2 was in his wheelchair in front of Resident #1 who was lying in bed holding her teddy bear tight on her chest. LVN A said Resident #2 had his left hand, three fingers inside Resident #1's vagina moving in a back, forth and circle motion. LVN A said she could see the vaginal hair on Resident #1. LVN A said Resident #1 was lying there doing nothing with a blank stare on her face and it didn't look like Resident #1 was enjoying it. LVN A said Resident #2 looked like he enjoyed it because he had a smile on his face. LVN A said she separated the residents, escorted Resident #2 out of the room to get to safety and to get interviews. LVN A said Resident #2 told her as she was pushing him down to 100 hall, that they both were enjoying it. LVN C said she took Resident #2 to hall 100 to be on 1:1 with CNA C who was also a male. LVN C said she went back to Resident #1's room to assess and interview her with the ADON and CNA B. LVN A said she completed the assessment on Resident #1 and there was no bruising, no blood and no complaints of pain. LVN A said she assessed Resident #1 vaginal area and there was no blood or discharge, no bruising and no open areas. LVN A said Resident #1 said she told Resident #2 to stop twice. LVN A said Resident #2 was more alert than Resident #1. LVN A said she called both the residents RP and left a message for them to call back and notified the DON and the Administrator. LVN A said she was in-service on and was knowledgeable of abuse and neglect, abuse coordinator is the administrator, immediately report abuse and neglect, signs and symptoms on how to identify inappropriate sexual behaviors, how to redirect and residents' rights as it related to consensual and non-consensual sex or intimacy. LVN A said the Police were called and she was interviewed along with ADON, CNA B and the two residents involved.During an interview on 08/16/2025 at 4:08 p.m., the ADON said she was in the conference room and CNA B came and got her. The ADON said she did not see the actual act, but she was headed to the room. She said she saw LVN A was taking Resident #2 out of Resident #1's room by the wheelchair and Resident #2 was asking what's wrong saying he didn't do nothing wrong; we were two consenting adults. The ADON said Residents #1 and #2 were immediately separated. Resident #2 was taken to hall 100 to do 1:1 and she interviewed Resident #1 along with LVN A and CNA B. The ADON said when she saw Resident #1, she did not seem afraid and was not crying and said she did not give consent, he (Resident #2) came into her room and told her to lay back. The ADON said Resident #1 said she grabbed her baby which was a bear and put it on her lap and then he (Resident #2) asked her (Resident #1) to lay back again, and Resident #2 started touching her vaginal area. The ADON said Resident #1 said she wasn't OK with that, when Resident #2 first started touching her vaginal area and she didn't enjoy it at first but then later she said she did start to enjoy it. The ADON said Resident #1 also told her they were friends, and she was not OK at first with him digging in her brief. The ADON she said she interviewed Resident #2 within 10 minutes of the incident. She said Resident #2 told her Resident #1 was fine with him touching her vaginal area and Resident #1 didn't tell him to stop, he didn't ask her if he could touch her, they were two consenting adults, Resident #1 didn't stop me, he figured it was OK because she never told him no and Resident #2 said Resident #1 was his friend. The ADON said the assessment of the resident, the female resident, was done by LVN A and CNA B washed Resident #2's hands. The 1:1 sitter said Resident #1 said she wasn't hurt and didn't want to go to the hospital. They called the RP and at first they had to leave a message but then he showed up the next day and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675172 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete he was notified and didn't want to send Resident #1 to the hospital. The ADON said she called the doctor, and new orders were to send Resident #2 to the behavior hospital. The ADON said the Police were called and she was interviewed along with LVN A, CNA B and the two Residents involved. The facility implemented the following interventions prior to the state surveyors entrance:Interviews conducted on 08/16/2025 from 3:30 p.m. through 08/16/2025 at 5:30 p.m., with the following staff through various shifts (6a-6p, 6p-6a, 6a-2p, 2p-10p, and 10p-6a) the DON, the ADON, LVN A, CNA B, Dietary O, CNA C, CNA D, Admissions, BOM, HR, CNA E, Dietary F, CNA G, CNA H, laundry I, CNA J, Rehab K, CNA L, LVN M, Dietary N, Dietary P, LVN Q, CNA R, LVN S, CNA T, Laundry U, LVN V, CNA W, LVN Y, CNA Z, Rehab AA, LVN X, CNA BB, LVN CC, CNA DD, Housekeeper EE, CS FF, Housekeeper GG, and LVN HH the staff said they were trained on abuse/neglect, abuse reporting, resident rights on hire and at least annually. The staff said they were retrained following the incidents that occurred on 08/14/2025. They were able to voice what to do first such as separate the residents and get help as needed. They said they would report to the Administrator who was the abuse coordinator. They were able to identify different types of abuse (examples of verbal, sexual and physical). Staff said they were trained to be alert to intimate acts between residents and to report to the nurse or management immediately. Staff understood residents had rights to sexual expression if it was consensual and identify those with capacity to consent and to report all acts of sexual expressions to nursing management for review for safety of both residents.Record review indicated on 08/14/2025, the DON held an in-service on the following with 54 employees in attendance:-resident rights,-abuse, neglect, and abuse reporting, -alert to intimate acts between residents, - resident safety and both residents able to give consent, recognizing concerns and,-identifying sexual abuse and capacity to consent.Attendees included 15 licensed nurses, 18 CNAs, 3 rehabilitation staff, 7 dietary staff, 4 housekeepers, 1 SW, 1 laundry, and 5 office personnel.The noncompliance was identified as PNC. The IJ began on 08/14/2025 at 12:08 p.m. and ended on 08/14/2025 at 6:34 p.m. The facility had corrected the noncompliance before the survey began. Event ID: Facility ID: 675172 If continuation sheet Page 7 of 7