**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a Comprehensive Person-Centered Care Plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for 3 of 27 sampled residents, Residents (R) 14, R33, and R58. On 08/10/2023, facility staff observed R33 in R14's room with his hands under R14's shirt. However, the facility failed to develop R33's Comprehensive Care Plan (CCP) to include interventions to address supervision and monitoring of the resident. On 09/01/2023, facility staff observed R33 in R58's room with his hand on R58's breast. Again, the facility failed to develop interventions for R33's inappropriate sexual behaviors in his CCP. On 04/27/2024, facility staff found R33 in R58's room with his hands inside R58's open brief, and her night clothing pulled up to expose her breasts. The facility again failed to develop a CCP for R33 which addressed his inappropriate sexual behavior and need for supervision and monitoring him in order to protect other residents. Immediate Jeopardy (IJ) was identified on 10/16/2024 at 42 CFR 483.21 Develop and Implementation of a Comprehensive Person-Centered Care Plan (F656) at a Scope and Severity (S/S) of a J. The IJ was determined to exist on 08/10/2023. The facility was notified of the IJ on 10/16/2024. An acceptable Immediate Jeopardy Removal Plan was received on 10/19/2024, which alleged removal of the IJ on 04/30/2024. The State Survey Agency (SSA) validated the IJ was removed on 04/30/2024. Refer to 689 The findings include: 1(a). Review of R14's admission Record revealed the facility admitted the resident on 12/13/2017, with diagnoses of Parkinsonism, dementia, anxiety disorder, and heart disease. Review of R14's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of seven out of 15, indicating severe cognitive impairment. Review of R14's CCP dated 08/04/2023, revealed the facility identified a problem for the resident as at risk for feelings of isolation. 1(b). Review of R33's admission Record revealed the facility admitted the resident on 09/11/2015 with diagnoses which included aphasia, cerebral infarction, osteoarthritis, and hemiplegia and hemiparesis. Review of R33's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 99, which indicated he was unable to complete the interview. Further review revealed the facility also assessed R33 to have modified independence with making decisions. Review of the facility's investigation, dated 08/10/2023, revealed at 3:20 PM, the Administrator was notified that the Activity Director had walked into R14's room and found R33 with his hand up R14's shirt. The facility placed R33 on increased monitoring for eight (8) hours with no issues identified. Review of R33's (CCP), revealed the facility developed a problem for mood/behaviors dated 08/11/2023 (the day after the sexually inappropriate incident). Per review, the facility developed the problem with mood/behaviors related to a history of socially inappropriate/disruptive behavior and noncompliance with medications and care. Continued review of the mood/behavior care plan revealed R33 had a history of wandering into (other) residents' rooms uninvited, and had a history of sexually inappropriate behaviors towards other residents. Further review revealed the interventions the facility developed for R33 included administering medications as ordered; monitoring the resident for pocketing medications, and removing him from public areas when his behavior was disruptive or inappropriate. However, additional review of R33's CCP revealed no documented evidence the facility developed interventions such as: removing R33 from other residents' rooms; monitoring him for sexual behaviors; and/or monitoring or supervising the resident to prevent further incidents. In interview on 10/19/2024 at 2:05 PM, the Regional [NAME] President of Operations (VPO) stated the facility's intent for the (CCP) intervention of removal of R33 from public areas when his behavior was disruptive/inappropriate was to watch him while in the hallway to keep him from going into other residents' rooms. She stated she considered residents' rooms as public areas. In interview on 10/19/2024 at 5:25 PM, the Social Services Director (SSD) stated she updated R33's CCP for removing him from public areas when his behavior was disruptive/inappropriate. The SSD further stated she did not consider other residents' rooms as public areas. In interview on 10/16/2024 at 4:51 PM, R14's family member stated the facility placed a Velcro stop sign over the resident's door entrance. Per R14's family member, the facility explained the stop sign placed over R14's door entrance as due to her having a urinary infection and required the stop sign. In continued interview on 10/19/2024 at 5:25 PM, the SSD stated she updated R14's CCP to include the stop sign. 2. Review of R58's admission Record revealed the facility admitted the resident on 08/17/2023, with diagnoses of Alzheimer's Disease, femur fracture, and anxiety. Review of 58's admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS' score of 99, indicating the resident had not been able to complete the interview. Further review revealed the facility assessed R58's cognitive skills for decision making as severely impaired. Review of R33's progress note dated 09/01/2023 at 11:56 AM, documented by Licensed Practical Nurse (LPN) 4, revealed staff found R33 in R58's room with her shirt pulled up and him touching R58's breast. Further review revealed the facility placed R33 on one to one (1:1) monitoring. Review of the facility's investigation, dated 09/01/2023, revealed at 10:35 AM, a Certified Nursing Assistant (CNA) notified the SSD, who notified the Administrator, that the CNA walked into R58's room and saw R33 sitting in his wheelchair with his hand up R58's shirt, touching her breast. R33 was placed on 1:1 monitoring and was referred to the hospital's behavioral health unit. R33 and R58 were placed on acute 72-hour charting to identify any signs or symptoms of psychosocial decline. However, review of R33's CCP revealed no revisions to the resident's mood/behavior care plan immediately following the incident on 09/01/2023. Review of R33's CCP revealed a psychotropic medication care plan initiated 09/08/2023, for the resident's risk for adverse medication effects. Per review of the psychotropic medication care plan, the facility initiated interventions for administering R33's medications as ordered, and to monitor and document R33's target behaviors. Further review of R33's CCP revealed no documented evidence the facility care planned R33 for 1:1 monitoring. Review of R58's CCP revealed no evidence the facility developed the resident's CCP, following the incident on 09/01/2023, to include interventions for her protection from further sexual abuse by other residents. In interview on 10/16/2024 at 1:36 PM, Licensed Practical Nurse (LPN) 7 stated R33 had been placed on 1:1 monitoring at the time of the 09/01/2023 incident and, after the 1:1 monitoring was completed, all staff knew they were to keep an eye on R33. The LPN stated the task for keeping an eye on R33 had not been assigned to anyone specifically. LPN 7 stated it was possible R33 could have gone into another resident's room during that time. In interview on 10/19/2024 at 2:05 PM, the Regional VPO stated R33's target behaviors were the ones stated in the mood/behavior care plan which included socially inappropriate/disruptive behavior, noncompliance with medications and care, history of wandering into other residents' rooms uninvited, and a history of sexually inappropriate behaviors towards other residents. 3. Review of the facility's investigation documentation dated 04/27/2024, revealed Certified Medication Technician (CMT) 1 had seen R33 in R58's room. Continued review revealed R33 had been sitting in his wheelchair leaning over R58, who was lying on her bed. Per review, R33's hand was inside R58's unfastened brief. Further review revealed R33 was removed from R58's room and placed on 1:1 monitoring, and R58 was referred for psychiatric (psych) services. Review of R58's progress note dated 04/27/2024 at 11:55 PM, revealed staff found R33 in R58's room with his hand down her brief and her shirt pulled up exposing her breast. Further review of the note revealed R58 was asked if she wanted R33 in her room touching her and the resident stated, No. In interview on 10/16/2024 at 10:30 AM, CMT 1 stated she had been walking down the hallway on 04/27/2024 and had seen R33 in R58's room with his hand inside R58's opened brief. She stated she had to physically remove R33's hand from inside R58's brief. CMT 1 stated R33 was placed on 24 hours of 1:1 supervision for 24 hour monitoring after that incident. The resident continued on the 1:1 monitoring since his return from the hospital's behavioral health unit. Additionally, CMT 1 stated she notified the supervising nurse immediately of the incident. CMT 1 further stated she was unaware if either residents' care plan was updated following the incident. Review of R58's social services (SS) progress note dated 04/29/2024 at 8:29 AM, revealed staff reported R58 had (displayed) tearful behaviors last night. Continued review of the note revealed a stop sign was to be hung on R58's door and the resident to be referred to psych services. Review of R33's CCP revealed the facility's interventions, initiated on 04/28/2024, included monitoring the resident for behaviors when out of his room. Continued review revealed the interventions also included redirecting R33 when he went into another resident's room, and providing 1:1 monitoring for behaviors. In interview on 10/17/2024 at 3:35 PM, the Administrator stated R33 was originally care planned for 1:1 monitoring after the 04/27/2024 incident; however, the wording had been changed (she was not sure when) as the facility was trying to place R33 in another facility. The Administrator further stated no one would take him with 1:1 monitoring charted (in his medical record). The Administrator additionally stated she felt the resident's care plans were updated correctly with interventions that were effective at the time of the incidents. In interview on 10/19/2024 at 5:25 PM, the Social Services Director (SSD) stated she updated R33's CCP with new interventions for behaviors. However, she did not include the intervention of 1:1 monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision to prevent sexual abuse for 3 of 27 sampled residents (Residents (R)14, R33, and R58). On 08/10/2023, staff found R33 in R14's room with his hands under R14's shirt. The facility failed to assess R33's risk for inappropriate sexual behaviors to prevent further incidents placing other residents at risk for sexual abuse. The facility created a Mood/Behaviors Care Plan on 08/11/2023 for R33; however, they failed to develop and implement interventions for the resident in order to protect other residents from potential risk of sexual abuse by him. On 09/01/2023, staff found R33 in another resident's room (R58's) with his hand under her shirt touching her breast. The facility again failed to implement care plan interventions to protect other residents from further sexual abuse by R33. On 04/27/2024, staff found R33 in R58's room with his hands inside R58's opened brief, and her night clothing pulled up exposing her breast. In addition, the facility failed to provide documented evidence R33, R14, and R58 were assessed for their capacity to consent to sexual activity. The facility's failure to have an effective system to ensure residents received adequate supervision to prevent sexual abuse was likely to cause serious injury, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 10/16/2024 at 42 CFR 483.25 Accidents and Supervision (F689) with a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Accidents and Supervision (F689). The IJ was determined to exist on 08/10/2023. The facility was notified of the IJ on 10/18/2024. An acceptable Immediate Jeopardy Removal Plan was received on 10/19/2024, which alleged removal of the Immediate Jeopardy on 04/30/2024. The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 04/30/2024 and determined to be past IJ. Refer to F656 The findings include: Review of the facility's policy titled, Abuse, Neglect, Protection, Prevention, and Reporting Policy, effective 08/04/2024, revealed the facility was to establish a safe environment that supported, to the extent possible, a resident's safety. Continued review revealed the facility was to identify, correct, and intervene in situations in which abuse was more likely to occur. Further review revealed the facility's Administrator was to identify, intervene, and correct situations in which reported abuse might recur. Review of the facility's policy titled, Resident Rights Policy, effective 08/13/2024, revealed all residents had the right to be treated with respect, dignity, and in a manner and environment that promoted maintenance or enhancement of quality of life. Further review revealed the facility was to make every effort to support each resident in exercising his/her right to assure the resident was always treated with respect, kindness, and dignity. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, revised 06/20/2024, revealed the interdisciplinary team (IDT) was to thoroughly evaluate new or changing behavioral symptoms in residents. Per review, the IDT was to thoroughly evaluate such residents' behaviors in order to identify underlying causes and address any modifiable factors that might have contributed to the resident's changing condition. Continued review revealed safety strategies were to be implemented immediately if necessary to protect the resident and others from harm. Further review revealed the Director of Nursing (DON) or designee was to evaluate whether the staffing needs changed based on acuity of the residents and their plans of care. Additional review revealed staff and/or staff training was to be provided if it was determined the needs of the residents could not be met with the current level of staff or staff training. 1(a). Review of R33's admission Record revealed the facility admitted the resident on 09/11/2015, with diagnoses which included aphasia, cerebral infarction, osteoarthritis, and hemiplegia and hemiparesis. Review of R33's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. Further review revealed the facility assessed R33's mental status as modified independence with decision making. Review of R33's Comprehensive Care Plan (CCP) dated 08/11/2023, revealed the facility identified a problem with mood/behaviors with a history of socially inappropriate/disruptive behavior and noncompliance with medications and care for the resident. Continued review revealed R33, at times, attempted to pocket medications, had a history of wandering into residents' rooms uninvited and had a history of sexually inappropriate behaviors towards others. Further review revealed the interventions included: administering medications as ordered; monitoring the resident for pocketing medications; and removing from public areas when his behavior was disruptive/inappropriate. Additional review revealed no documented evidence the facility implemented interventions for R33's increased monitoring or for R33 wandering into other residents' rooms uninvited. Review of the facility's investigation dated 08/10/2023, revealed at 3:20 PM, the Administrator was notified by the Activity Director (AD) that when the AD walked into R14's room the AD observed R33 with his hand up R14's shirt. Further review of the investigation revealed the facility placed R33 on increased monitoring for eight hours with no issues identified. Review of R33's progress note, dated 08/10/2023 at 5:50 PM, written by Registered Nurse (RN) 3, revealed the resident's responsible party was notified the resident was on increased monitoring. Per review, R33's responsible party was also notified the resident was not to visit other female residents in their rooms. Review of R33's progress note dated 08/11/2023 at 11:48 AM, written by the Social Services Director (SSD) revealed the resident was in his room with no signs or symptoms of psychosocial distress. Review of the facility's 15-Minute Watch Log, for R33 dated 08/10/2023, revealed the facility placed the resident on one to one (1:1) monitoring for (2) hours; then on every 15-minute checks for 2 hours. Continued review of the Log revealed the facility then placed R33 on every 30-minute checks for 2 hours; and then hourly checks for 2 hours. Further review revealed the Watch Log was only initialed by staff with no documented evidence of the resident's behaviors. During interview with R33's family member on 10/16/2024 at 12:27 PM, the family member stated the facility did not notify her of the incident on 08/10/2023. During interview on 10/19/2024 at 5:25 PM, the SSD stated she updated R33's CCP for wandering and 1:1 monitoring. The SSD stated she considered public areas to be hallways including leading into the residents' rooms. She stated she did not consider residents' rooms to be public areas. 1(b). Review of R14's admission Record revealed the facility admitted the resident on 12/13/2017, with diagnoses that included dementia, anxiety disorder, heart disease, and Parkinsons. Review of R14's Annual MDS Assessment, dated 06/22/2023, revealed the facility assessed the resident to have a BIMS' score of seven out of 15, which indicated she was severely cognitively impaired. Review of R14's CCP, dated 08/04/2023, revealed the facility identified a problem for the resident as at risk for feelings of isolation. Continued review revealed an intervention, dated 08/15/2023, to place a privacy sign across R14's room doorway. Review of R14's progress note, dated 08/11/2023 at 11:44 AM, written by the SSD revealed R14 showed no signs or symptoms of psychosocial distress. Continued review of R14's progress notes revealed no further documentation regarding R14's psychosocial well-being until 08/14/2023 at 9:36 AM, when nursing staff noted the resident had no signs of psychosocial distress. In interview with R14's family member on 10/16/2024 at 4:51 PM, the family member stated a facility staff member called her and advised her a male resident had wandered into R14's room. Per the family member, the staff member asked if it was okay for the male resident to visit R14. The family member stated she answered, yes because she was never informed the male resident might have or might not have touched R14 inappropriately. R14's family member stated the facility placed a velcro stop sign over the resident's door entrance, but facility staff said it (the stop sign) was over the door entrance because she had an infection and required it. During interview on 10/17/2024 at 3:35 PM, the Administrator stated she investigated the allegation regarding R33 and felt the eight hours of increased monitoring had been sufficient as the resident had no further behaviors during those eight hours. During interview on 10/19/2024 at 2:05 PM, the Regional [NAME] President of Operations (VPO) stated the intent of the care plan intervention for removing R33 from public areas when his behavior was disruptive/inappropriate was to watch for residents in the hallway to keep him from going into other residents' rooms. She stated she considered residents' rooms to be public areas. During interview on 10/19/2024 at 5:25 PM, the SSD stated she updated R14's CCP to include a stop sign. 2(a). Review of R33's CCP revealed no documented evidence of further revisions to the resident's mood/behavior care plan after the incident on 08/10/2023. Review of R33's progress note, dated 09/01/2023 at 11:56 AM, documented by LPN 4, revealed staff found R33 in R58's room with R58's shirt up and R33 touching her breast. Further review revealed R33 was placed on 1:1 monitoring. Review of the facility's investigation documentation dated 09/01/2023, revealed at 10:35 AM, a Certified Nursing Assistant (CNA) notified the SSD that R33 was in R58's room. The SSD notified the Administrator of the incident Per review, R33 was placed on 1:1 monitoring and was referred to the hospital's behavioral health unit. Further review revealed R33 and R58 were placed on acute 72-hour charting to identify any signs or symptoms of psychosocial decline. Review of the facility's Social Service (SS) progress note dated 09/01/2023 at 2:56 PM, revealed R33 had been accepted to the hospital's behavioral health unit. Review of the facility's Health Status Progress Note for R33, documented by Unit 2 Manager, dated 09/07/2023 at 11:37 AM, revealed R33 had refused all medication while at the behavioral health unit and was returning with no changes. Further review revealed staff from the behavioral health unit stated there was nothing more they could do for R33. Review of the facility's progress note dated 09/07/2023 at 1:45 PM, documented by LPN 4, revealed R33 returned to the facility. Review of the facility's Health Status Progress Note, dated 09/07/2023 at 3:02 PM, documented by Unit 2 Manager, revealed R33 was oriented to the new room as an intervention for recent behavior. Further review revealed R33's ordered Paxil (an antidepressant) to be administered for the resident related to other specified depressive episodes. During interview on 10/16/2024 at 12:27 PM, R33's family member stated the facility only disclosed one incident to her and she was unaware of the incident on 09/01/2023. During interview, on 10/16/2024 at 2:31 PM, LPN 4 stated she did not remember the incident (on 09/01/2023), but would have charted everything accurately. LPN 4 stated for any abuse allegations she would notify her supervisors, including the DON and Administrator as well as the Physician and resident's responsible party. During interview on 10/17/2024 at 3:35 PM, the Administrator stated she felt the 1:1 monitoring of R33 following the incident on 09/01/2023, and the order for Paxil upon the resident's return from the behavioral health unit were effective. She stated she felt the 1:1 monitoring and Paxil had been effective because R33 had no further episodes of sexual behavior until April 2024. 2(b). Review of R58's admission Record revealed the facility admitted the resident on 08/17/2023, with diagnoses of femur fracture, anxiety, and Alzheimer's Disease. Review of R58's admission MDS Assessment, dated 08/19/2023, revealed the facility assessed the resident to have a BIMS' score of 99, which indicated the resident was unable to complete the interview. Further MDS review revealed the facility assessed R58's cognitive skills for decision making as severely impaired. Review of R58's Psychosocial CCP, dated 08/29/2023, revealed R58 was at risk for feelings of isolation from family and friends with interventions which included to encourage the resident to talk about her feelings. However, there was no documented evidence the facility addressed the resident's psychosocial well-being or safety from abuse. Review of R58's CCP revealed no evidence the facility updated the CCP following the incident. Review of the facility's progress note dated 09/01/2023 at 12:20 PM, documented by LPN 4, revealed R58 was in a pleasant mood, and the family was aware of the incident. However, further review of R58's progress notes revealed no documented evidence indicating the specific details of the incident. During interview on 10/16/2024 at 1:36 PM, LPN 7 stated R33 had been placed on 1:1 monitoring (after the incident on 09/01/2023). The LPN stated after the 1:1 monitoring was completed all staff knew they were to keep an eye on R33, but the task was not specifically assigned to anyone. LPN 7 stated it might been possible for R33 to have gone to a different room during that time. 3(a). Review of R33's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of 99, indicating the resident was unable to complete the interview. Further review revealed the facility assessed R33 to have modified independence with decision making. Review of R33's CCP, initiated on 08/11/2023, for the resident's risk for mood/behaviors revealed the facility initiated interventions on 04/28/2024, to include monitoring R33 for behaviors when he was out of his room and redirecting him when he went into another resident's room. Review of the facility's investigation documentation dated 04/27/2024, revealed Certified Medication Technician (CMT) 1 saw R33 in R58's room. Per review, R33 was sitting in his wheelchair leaning over R58, who was lying on her bed. Continued review revealed R33 had his hand inside R58's brief which was unfastened. Further review revealed R33 was removed from the room and placed on 1:1 monitoring. Additional review revealed the facility referred R33 for weekly psychiatric (psych) services for evaluation and monitoring (after the incident). Review of the Police Call Response Run Report, dated 04/27/2024 at 11:30 PM, revealed an officer interviewed R33 and noted the resident showed no regrets for his actions. Review of R33's progress note, dated 04/29/2024 at 1:19 PM, documented by the SSM, revealed R33 had been accepted to the hospital's behavioral health unit. Review of the hospital psychiatric discharge summary for R33, dated 05/27/2024 at 8:23 AM, revealed the resident was noted as sexually aggressive with staff and other residents. Per review, R33 was also noted to often wait until an opportunity presented itself to touch other residents. Further review revealed R33 had to have constant monitoring and redirection. Review of the facility's progress record documentation for R33, dated 07/18/2024, revealed the resident's Physician stated due to the safety of individuals in the facility including residents and staff, we are unable to meet his needs due to his multiple sexual inappropriate gestures to residents. All measures have been exhausted. 3(b). Review of the facility's Quarterly MDS assessment dated [DATE], revealed the facility assessed R58 to have a BIMS' score of 99, which indicated she was unable to complete the interview. Further MDS review revealed the facility assessed R58's cognitive skills for decision making as severely impaired. Review of R58's CCP revealed no evidence the facility further developed the CCP with new interventions for the resident's safety and well-being following their investigation. Review of R58's progress note dated 04/27/2024 at 11:55 PM, revealed facility staff found R33 in R58's room with his hand down inside her brief and her shirt pulled up with her breast exposed. Continued review revealed R58 was asked if she wanted R33 in her room touching her and she stated No. Further review revealed R58 was scared, and there was redness noted to her labia upon skin assessment. Review of the facility's progress note for R58 dated 04/28/2024 at 12:44 PM, revealed the resident was noted to have had no psychosocial changes (as a result of the incident on 04/24/2024). Review of the facility's SS progress note for R58, dated 04/29/2024 at 8:29 AM, documented by the SSD, revealed staff reported R58 had tearful behaviors last night. Further review revealed a stop sign was to be hung on R58's door and the resident referred to psych services. Review of the psychiatry diagnostic interview documentation for R58 dated 05/07/2024, revealed it was the initial evaluation for the resident for follow-up on an incident involving R33. Per review, staff reported since the incident R58 had experienced one episode of tearfulness. Continued review revealed R58 had limited verbal ability and smiled and nodded during the assessment. Further review revealed R58 had been unable to answer questions appropriately due to her severely impaired cognition related to Alzheimer's Disease. In addition, review of the documentation revealed recommendations for staff to monitor and document any changes in R58's mood. During interview on 10/16/2024 at 10:30 AM, CMT 1 stated she was walking down the hallway on 04/27/2024 and saw R33 in R58's room with his hand inside R58's opened brief. CMT 1 stated she had to physically remove R33's hand from inside R58's brief. CMT 1 stated R33 was placed on 24 hour 1:1 monitoring after that second incident with R58, and had continued on 1:1 monitoring since he returned from the hospital's behavioral health unit. CMT 1 further stated R33 was known, by the facility staff, to have had behavioral issues since 2020. During an interview on 10/21/2024 at 10:36 AM, the Medical Director stated he was aware of R33's behaviors and the resident was the facility's problem child. He stated he and another Physician were co-Medical Directors of the facility. The Medical Director stated he and the other Physician had conferred and believed the only way to keep other residents safe at the facility was to keep R33 on 1:1 monitoring until he could be placed in another facility. In an interview, on 10/17/2024 at 3:35 PM, the Administrator stated the facility had provided interventions for each incident which she felt were effective.