GAFFNEY, SC - Federal inspectors cited Brookview Healthcare Center for immediate jeopardy violations after facility staff failed to properly respond to and report an alleged sexual assault involving a cognitively impaired resident in February 2025.
Incident Discovery at 1 AM
On February 4, 2025, at approximately 1:00 AM, nursing staff discovered a 56-year-old male resident with schizoaffective disorder completely unclothed on top of a 77-year-old female resident in her room. The female resident, who had severe cognitive impairment with a score of 4 out of 15 on cognitive assessment, was found with her covers removed, gown pulled up, and brief displaced.
According to employee statements reviewed during the inspection, staff had been searching for the male resident for approximately 10 minutes after he wandered from the nursing station. A registered nurse located him after hearing running water in the female resident's room. The sink was found overflowing when staff entered.
The male resident was immediately removed from the room and transported to the emergency department for psychiatric evaluation. However, the female victim was not sent for medical evaluation at that time, despite the nature of the incident.
Delayed Notification and Inadequate Assessment
Critical failures in the facility's response became apparent during the investigation. The female resident's family was not notified until more than 24 hours after the incident occurred. The Director of Nursing (DON) did not contact the resident's daughter until February 5, 2025, between 10:30 AM and 11:00 AM.
During that phone call, the DON reportedly told the family member that staff had assessed the resident twice and found no injuries. According to the DON's statement to investigators, facility staff concluded there was "no evidence that he penetrated her" based on visual assessments that found "no redness, no discharge, no bruises."
The licensed practical nurse who conducted the initial assessment stated she performed only a visual examination. Documentation revealed that proper assessment procedures were not followed. The nurse acknowledged to investigators that "typically it should have been done on paper, and filled out to its entirety."
Medical Standards for Sexual Assault Response
Federal regulations require nursing homes to protect residents from all forms of abuse, including sexual assault. When such incidents occur, immediate comprehensive medical evaluation by qualified sexual assault nurse examiners (SANE) is the standard protocol.
Visual assessments by facility nursing staff are insufficient for sexual assault cases. Physical evidence may not be immediately visible, and trauma can occur without external signs. Additionally, victims may be at risk for sexually transmitted infections, internal injuries, and psychological trauma that require specialized evaluation and treatment.
The 77-year-old victim's severe cognitive impairment made proper medical assessment even more critical. Residents with dementia cannot reliably communicate pain or discomfort, and her documented communication pattern of saying "yes" as her primary response made verbal assessment unreliable.
Hospital Evaluation Reveals Different Picture
After the family insisted on hospital evaluation, the resident was transported to the emergency department on February 5, 2025. Hospital records documented the incident as a "potential sexual assault" requiring SANE team evaluation.
Emergency department notes indicated the facility nurse reported to hospital staff that "the male patient was found fully naked on top of [the female resident]" and that the resident's "diaper was pulled to the side and male was attempting to take it off." Hospital documentation also noted uncertainty about whether penetration had occurred.
The SANE team completed their evaluation and contacted law enforcement. According to the family representative's statement to investigators, police interviewed the male resident, who reportedly made statements acknowledging inappropriate contact.
Reporting Failures
Federal regulations require nursing homes to immediately report allegations of abuse to the state survey agency and law enforcement. Brookview Healthcare Center failed to meet this obligation.
The facility's own policy stated that "facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring" and required reporting "allegations and substantiated occurrences of abuse" to state agencies and law enforcement.
Despite this clear policy, the facility did not report the incident to the state survey agency. The state ombudsman, who visited the facility on a routine visit after the incident occurred, stated that no one at the facility reported anything about the incident during that visit.
The facility's administrator told investigators the DON was "responsible for reporting, and this incident should have been reported." When asked why it was not reported, the administrator stated she was "unsure as to why the DON did not."
Cognitive Impairment and Vulnerability
Both residents involved had significant cognitive impairments that placed them at higher risk. The female victim had severe dementia, was non-ambulatory, and could not independently change position or call for help. She required total assistance for mobility and could not get out of bed without staff support.
The male resident had documented diagnoses including schizoaffective disorder, psychotic disorder with hallucinations, and a history of wandering behavior. His quarterly assessment identified him as being at risk for elopement due to cognitive impairment, poor decision-making skills, ambulatory status, and wandering history.
Nursing homes are responsible for developing care plans that address these risk factors and implementing appropriate supervision and monitoring to prevent harmful resident-to-resident interactions.
Systemic Supervision Breakdown
The incident revealed gaps in facility monitoring procedures. Staff statements indicated the male resident was sitting at the nursing station when he walked down the hall. However, staff did not immediately notice his absence or track his location.
The 10-minute period during which the resident was unaccounted for was sufficient time for him to travel to another unit, enter the female resident's room, and initiate the assault. This gap in supervision was particularly problematic given his documented history of wandering and cognitive impairment.
Federal standards require nursing homes to provide adequate supervision based on residents' assessed needs and risk factors. When residents have conditions that create safety risks - such as wandering behavior, cognitive impairment, or behavioral issues - facilities must implement appropriate monitoring systems.
Facility Response and Corrective Actions
The facility provided an immediate jeopardy removal plan on February 28, 2025. The plan included sending the male resident to a psychiatric hospital unit and confirming the female resident was evaluated at the hospital.
Corrective measures implemented by the facility included mandatory training for all staff on sexual abuse prevention, additional training for the DON on reportable incidents, establishment of protocols requiring administrator notification of unusual occurrences involving residents, and implementation of incident review processes at morning meetings.
The facility also committed to monitoring these incidents through their quality assurance program, with monthly reviews for three months and quarterly reviews thereafter.
Regulatory Citations
Inspectors cited the facility for two violations. The primary citation was F600, related to freedom from abuse and neglect, which resulted in an immediate jeopardy determination. This is the most serious level of deficiency, indicating a situation where the facility's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death to a resident.
The facility also received a citation for F609, related to timely reporting of suspected abuse. This violation was categorized as having minimal harm or potential for actual harm.
Impact on Resident Rights
Federal regulations guarantee nursing home residents the right to be free from abuse, neglect, and exploitation. This includes protection from resident-to-resident incidents when facilities have knowledge of risk factors that could lead to harm.
The failure to immediately notify family members, provide proper medical evaluation, and report to authorities violated multiple aspects of resident rights. Family members have the right to be promptly informed of significant changes in their loved one's condition or any incidents that affect them.
Industry Context
Sexual abuse in nursing homes remains an underreported problem nationally. Cognitive impairment creates particular vulnerability, as residents may be unable to report abuse or defend themselves. Many victims cannot reliably describe what occurred due to dementia or other conditions affecting memory and communication.
Healthcare facilities that serve vulnerable populations must maintain robust prevention systems, including adequate staffing ratios, proper supervision protocols, thorough background checks, comprehensive staff training, and immediate response procedures when incidents occur.
The complete inspection report is available through the Centers for Medicare & Medicaid Services Nursing Home Compare website for residents and families seeking detailed information about care quality at Brookview Healthcare Center.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Blue Ridge In Brookview House, LLC from 2025-02-28 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.