**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # (AR 326) was substantiated, all or in part, with these findings. Based on interview and record review, the facility failed to ensure a thorough investigation was conducted after receiving an allegation of rape and failed to ensure protective measures were immediately implemented to prevent further potential abuse while the investigation was ongoing for 1 (Resident #1) of 1 case mix resident whose family member made an allegation of rape.

The facility also failed to ensure investigations were immediately initiated regarding allegations of possible staff-to-resident physical, verbal and / or emotional abuse and protective measures were immediately put in place to prevent further potential abuse for 2 (Residents #8 and #3) of 4 (Residents #3, #8, #9, and #10) sampled residents who, during the investigation of Resident #8’s allegations, were found to be the alleged victims of physical, verbal or emotional abuse by the same perpetrator (Nursing Assistant (NA) #1).

On 12/12/18 at 11:46 a.m., Resident #8 was sitting in the dining room of the secure dementia unit in a wheelchair. She asked the surveyor to come over to the table and stated, You need to check 11 to 7 (11:00 p.m. to 7:00 a.m. shift). The resident was asked to explain and stated, There is a man named (NA #1) he is mean, he threw me down, he said he would go get one of the 3-11 (3:00 p.m. – 11:00 p.m.) aides to put me in my place. He was helping me to the toilet and he threw me down on it. He said he would never help me again. He worked Monday (12/10/18) night. He was the only aide. At 11:54 a.m., the Surveyor went to the Nurses Desk and reported to Registered Nurse (RN) #1, the charge nurse for the secure dementia unit, the resident’s allegations. RN #1 stated, She did mention that to the unit manager yesterday (Licensed Practical Nurse (LPN #1)). He (NA #1) normally works up front, but he filled in Monday night / Tuesday morning here (on the secure unit). She told the same story to the Unit Manager. The Surveyor stated to RN #1, I am reporting an abuse allegation to you; what would be your responsibility with this allegation? She responded, Since it went directly to the unit manager yesterday, I would assume she suspended him and started an investigation.

On 12/12/18 at 5:00 p.m., the Administrator stated, We now have 3 new [MEDICATION NAME] (allegations of abuse) from this allegation, investigation, witness statements from 2 other residents and one CNA.