Blue Ridge In Brookview House, Llc

F-F600, constituting substandard quality of care.

Findings include:

Review of the undated facility policy titled Abuse and Neglect Prohibition, documented, .each resident has

the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property . Sexual Abuse - Includes, but is not limited to sexual harassment, sexual coercion, sexual assault . Prevention 2.) 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.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 8 425062 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425062 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookview Healthcare Center 510 Thompson Street Gaffney, SC 29340

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 Review of Resident R1's Face Sheet revealed Resident R1 was admitted to the facility on [DATE REDACTED], with diagnoses including, but not limited to: schizoaffective disorder, dementia, with other behavioral disturbance, epilepsy, and anxiety. Level of Harm - Immediate jeopardy to resident health or Review of Resident R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/24, safety revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating Resident R1 had severe cognitive impairment. Residents Affected - Few

Review of Resident R2's Face Sheet revealed Resident R2 was admitted to the facility on [DATE REDACTED], with diagnoses including, but not limited to: restlessness and agitation, psychotic disorder with hallucinations due to known physiological condition, Schizoaffective disorder, and Parkinsonism.

Review of Resident R2's Quarterly MDS with ARD of 01/17/25, revealed a BIMS score of 10 out of 15, indicating Resident R2 had moderate cognitive impairment.

Review of Resident R2's Quarterly Elopement Evaluation dated 01/13/25 at 9:05 AM, documented Resident R2 is ambulatory and/or Independent in wheelchair locomotion. Resident R2 is cognitively impaired, has poor decision-making skills, and/or pertinent diagnosis. Resident R2 has a history of wandering. Resident is at risk for elopement.

Review of Resident R2's Progress Note dated 02/04/25 at 1:07 AM, documented, Resident noted being physically aggressive with staff and other residents. Resident noted going into resident's room, pulling off the covers from resident, and screaming at different resident. Resident became physically and verbally combative with staff with staff was attempting to redirect resident. DON notified. EMS called for transport to ER for psych eval. Nursing

Review of Resident R1's Progress Note dated 02/05/25 at 11:23 AM, documented, LOA: Per daughter's (RP) request, res transported to CMC ER for exam. Res awake and alert. No s/sx of pain or distress noted. Nursing

During a phone interview with Resident R1's Representative (RP) on 02/27/25 at 10:28 AM, revealed that on 02/05/25, between 10:30 AM and 11:00 AM, the Director of Nursing (DON) contacted Resident R1's RP via phone and said on Monday night 02/03/24, going into 02/04/25, a male resident went missing and staff couldn't find him. When facility staff started looking for him, they heard water running from Resident R1's room, and staff went in the room, and found the male resident. Resident R2 was completely naked, and was actively trying to get Resident R1's brief off. The facility staff intervened and removed him from her room. Resident R1's RP stated the DON told her staff assessed the female resident that night, and the next morning, and she didn't have any trauma related to the event. Resident R1's RP stated Resident R1 has severe dementia, and will say yes as her only form of communication, and is non-ambulatory. Staff told her (Resident R1's RP) they didn't think that it was a big enough deal and since they didn't find anything, it was not a reportable offense. The DON told the RP the male resident was sent to the psych ward. Resident R1's RP stated, It killed me when I got the call, I requested them to send my mom to the hospital, because their assessments were not thorough enough in my opinion. Resident R1's RP further stated that Resident R1 went out to the hospital, no abrasions to the body or vaginal area. Police told her that Resident R2 was interviewed and admitted to

the police that Resident R2 put it in but not all the way, not enough to make babies. I called the ombudsman, and she gave me the department's information to file a complaint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 8 425062 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425062 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookview Healthcare Center 510 Thompson Street Gaffney, SC 29340

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 During an interview with the Attorney General Council for the [Local Hospital] Healthcare System via phone

on 02/27/25 at 1:55 PM, revealed that the internet is down and they would not be able to send the hospital Level of Harm - Immediate information until the internet is available. However, the Attorney General Council revealed Resident R1's HPI (history jeopardy to resident health or of present illness) revealed given concerns of potential sexual consult. safety

Review of Resident R1's HPI dated 02/05/25, documented, [Resident R1] is a 77 y.o. a female who presents to the emergency Residents Affected - Few department today given concerns over a potential sexual assault. History somewhat limited as patient does have a history of dementia, I am told by EMS that her care facility reported to the family that another individual with dementia may have exposed himself and had been on top her two days ago, the family had requested that she be transferred to the emergency department for further assessment. She does not have any acute complaints I am told she is mentating at baseline and does again have a known history of dementia, she will intermittently participate in the history and physical exam, and has not had any recent falls or other difficulties. ED Course Notes: SANE (Sexual Assault Nursing Examiners) has completed their evaluation, and was also able to discuss with the daughter. It sounds that the perpetrator of this event is actually not demented, but rather is a known schizophrenic. As a result SANE will contact the police department and has filed appropriate reports, we will continue to maintain patient safety until disposition can be made and we will discuss with the nursing facility prior to any plans to discharge home it sounds that this individual is also not currently at the facility so she would have a safe place to go. Police have evaluated the situation and appropriate reports filed per SANE team, patient safe to return to her care facility. Spoke with nurse at Brookview. She states the report she was given is that the event occurred at 2 am Tuesday morning. The male dementia patient at Brookview was lost for about 10 minutes. The male patient was found fully naked on top of [Resident R1]. [Resident R1] was also naked other than a diaper when found. Nurse states [Resident R1's] diaper was pulled to the side and male was attempting to take it off. Nurse states unsure if there was penetration. Bed Confined-Unable to ambulate, unable to get out of bed without assistance, unable to safely sit up in a wheelchair.

Review of Resident R2's HPI dated 02/04/25, documented, PT to ED via EMS from Brookview. Facility states pt had Aggressive behaviors. Pt is pleasant in triage. [Resident R2] is a 56 y.o male sent from Brookview with aggressive behavior. According to EMS, the patient was being aggressive towards other occupants at the facility. Patients denies this and state he just want to smoke. Unable to perform ROS (Review of Symptoms), Psychiatric disorder. Additional MDM and Provider Notes: [AGE] year-old male brought in by EMS from Brookstone for reported aggressive behavior towards other occupants of the facility. Patient has no knowledge of this and has very tangential thoughts. He has no complaints. CBC showed no leukocytosis, mild anemia. CMP shows reassuring electrolytes, normal renal function and liver function. UDS negative. Ethanol undetectable. Urinalysis not suggestive of a urinary tract infection. Awaiting telepsychiatrist recommendations. Patient signed out to the day team. Spoke with case management regarding the patient no longer being accepted at BrookView due to sexual assault against another [NAME] of BrookView. Case management will look at the patient for placement, however, the patient will not be able to have placement at

a facility with pending charges. Dr.notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 425062 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425062 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookview Healthcare Center 510 Thompson Street Gaffney, SC 29340

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 Review of an Employee Statement Form written by Certified Nursing Aide (CNA)1 dated 02/04/25 at 1:00 AM stated, On 2/4/2025 at 1AM, I noticed [Resident R2] was missing from the nurse's desk for a few minutes. I got up, I Level of Harm - Immediate went to his room and he was not in his room. I went to Dogwood, I asked the staff if they had seen [Resident R2], and jeopardy to resident health or they stated they heard him playing the piano in the dining room. [Registered Nurse (RN)2] got up, we went to safety the courtyard, and he was not in the courtyard. We went to the dining room, he was not in the dining room.

We looked outside of the dining room, called his name, and he was not outside of the dining room. We came Residents Affected - Few down the hall, I told [Licensed Practical Nurse (LPN)1] that i could not find [Resident R2]. I went into 150 thinking he may have gone in there to look for a radio. I heard [RN2] say he was in 157. I walked back up the hall into 157, I saw [Resident R2] putting on his shirt, and [LPN1] walked in at that time. [RN1] told [LPN1] about what was happening. I walked with [Resident R2] back to the nurse's desk on the peach and waited on EMS to come and get him.

Review of the Employee Statement Form written by LPN1 on 02/04/25 at 1:00 AM, documented, On 2/4/25 at around 1 AM, [Resident R2] was sitting at the nurse's desk on the couch. [Resident R2] got up and walked down the hall. [CNA1] asked if [Resident R2] was still sitting on the couch. This nurse said no, he walked down the hall. [CNA1] went to find the resident. [CNA1] walked over on the Dogwood unit and asked the Dogwood staff if the resident had walked by, and Dogwood staff said not recently. Dogwood staff went with [CNA1] to help locate the resident. [CNA1] came back to Peach nursing desk and informed this nurse and another cna that [Resident R2] was not located in the initial search. This nurse and [CNA2] went to Peach Short Hall, looking in rooms, the kitchen, and the laundry room. While walking back to the peach unit, this nurse heard [RN2] talking while coming on to peach unit via long hall. Staff was noted in room [ROOM NUMBER]. Particularly 157A in [Resident R1's] room. This nurse noted [Resident R2] standing beside of 157A'a bed with no pants on. [Resident R2] was yelling at staff and being aggressive. [RN1] explained she saw [Resident R2] on top of [Resident R1] when she entered the room then [Resident R2] got up and got dressed. This nurse took [Resident R2] to the nurses desk. This nurse notified the DON and called EMS to transport resident to the hospital. [CNA] stayed with [Resident R2] while this nurse went back to 157A's room to assess [Resident R1]. [Resident R1] was laying in bed on back. Upon inspection, resident noted to have brief intact, still adhered to both sides. The brief was pulled up the front, with the brief creating a thong like appearance, within the labia majoria. This nurse removed the brief. No redness, injuries, or bruising noted to the vulva or vagina area. Resident denied pain to that area. EMS arrived and escorted [Resident R2] to ER.

During an interview, via phone, with LPN1 on 02/27/25 at 2:24 PM, LPN1 confirmed her statement. LPN1 stated she is familiar with both residents. LPN1 stated she spoke to the DON, she and another nurse, and since her brief was intact, they didn't believe she was penetrated, or sexually assaulted which is why she was not sent to the hospital. LPN1 stated she spoke to the DON first, and informed she would take care of it all the following morning. LPN1 stated she did not notify Resident R1's family. LPN1 stated the assessments were visual. No documentation was filled out. Typically it should have been done on paper, and filled out to its entirety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 425062 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425062 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookview Healthcare Center 510 Thompson Street Gaffney, SC 29340

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 Review of an undated Employee Statement Form written by RN1, states, I was sitting at Dogwood desk working when [CNA1] from peach asked if I saw [Resident R2]. I told her not in the last little bit, but I heard him playing Level of Harm - Immediate the piano about 15 minutes ago. I went to help [CNA] look for the resident. After looking on Dogwood and in jeopardy to resident health or the dining room, the cna went to see if the other staff had seen the resident. Upon walking onto Peach Unit, I safety heard water running in 157 and knew neither resident could turn it on. When I opened the door the water in

the sink was on and about to over flow. I then saw [Resident R2] naked on top of [Resident R1] 157A. I told him to get off of her Residents Affected - Few right now. [Resident R1] was laying flat in bed with cover pulled off, Gown pulled up and brief slightly pulled to the side. At this time, other staff was in the room. This nurse asked [Resident R1] if she was okay and she just looked at me and finally said yes. [LPN1] took [Resident R2] out of the room to the desk. [LPN1] then called DON and EMS.

Attempt to interview, via phone, CNA1 on 02/27/25 at 1:05 PM, was unsuccessful and unable to leave a voicemail.

Attempt to interview, via phone, RN1 on 02/27/25 at 3:19 PM, was unsuccessful.

During an interview with the Director of Nursing (DON) on 02/27/25 at 12:19 PM, the DON she is aware of a situation between two residents, Resident R1 and Resident R2. LPN1 called her on 02/04/25 at 1 AM stating Resident R2 walked out of [LPN] and [CNA's] sight and they got up and started looking for him down the hall. They walked around the building to ensure he didn't make it out of the building. Dogwood nurse, located him in Resident R1's room, completely naked, on top of female resident. Female residents covers were pushed back, brief still on. The DON stated LPN1 yelled at him to get off her, and yelled for back up, and another nurse came in to assist the RN. LPN1 told me she assessed the resident. There was no evidence that he penetrated her. No redness, no discharge, no bruises. Female resident has dementia, and is not cognitive enough to say what would have happened to her. Male resident has psychosis issues, he had behavioral issues, however, not sexual, physical and verbal. The DON stated she hadn't had any issues with Resident R2. The DON stated it was her decision to not send Resident R1 to the hospital because Resident R1 did not have redness, or injury. The DON stated her fear was that if Resident R2 tried to do it and wasn't successful, he would try that with somebody else and didn't want him back at

the facility. The DON stated Resident R1's niece, who is a nurse in the facility and works on that unit messaged her on

the following night, it was on 02/04/24, and she found out upon getting the report. She asked me if Resident R1's daughter had been notified, and the nurse confirmed she hadn't called. The DON stated she would notify her

the following day on 02/05/25. The DON further stated on 02/05/25, she called the daughter and apologized

in regards to her not being notified the day it happened. The DON told the daughter, Resident R2 walked in Resident R1's room, had gotten in bed with Resident R1, and her brief was still on. The DON stated Resident R1's daughter requested Resident R1 to be sent out. The DON stated she told the daughter that she was assessed twice by facility staff and there were no injuries and that the male resident was sent out that night. The daughter still wanted her mother to get sent out.

During an interview with the Administrator on 02/27/25 at 3:40 PM, revealed she is familiar with both residents. The Administrator stated the DON told her that Resident R2 went into Resident R1 room. Resident R2 wandered off from LPN1's sight and ended up in Resident R1's room. Resident R2 was found naked, at Resident R1's bedside. The Administrator stated he was removed from the room. Resident R2 was sent out to the hospital for further evaluation. Resident R1 did not go, there was no indication it occurred. She was fine. She didn't remember anything having happened.

On 02/28/25 at 1:25 PM, the facility provided an acceptable IJ Removal Plan, which included the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 425062 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425062 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookview Healthcare Center 510 Thompson Street Gaffney, SC 29340

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 - Resident #2 was sent to the Hospital Psychiatric Unit.

Level of Harm - Immediate - Resident #1 was checked for any signs and symptoms of abuse. She was sent to hospital for further jeopardy to resident health or evaluation. safety - Resident #1 did not recall the incident occurring. Residents Affected - Few - All staff will receive additional training on Sexual Abuse by the Staff Development Coordinator starting 2/28/25 and will be completed by March 3, 2025.

- The DON was provided with additional training on reportable incidents by the Administrator on 02/27/25.

- The Administrator will be notified in addition to the Director of Nursing of all unusual occurrences involving two residents.

- All staff will be educated to the update of this procedure by the Staff Development starting 02/28/25 and will be completed by March 3, 2025.

- All incident reports will be brought to the Morning Meeting for review.

- The Administrator will monitor these incidents to ensure that any resident/resident incidents were reported to her.

Administrator will take findings of this monitoring tool to the QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further review.

The facility alleges that we were in compliance on 02/28/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 425062 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425062 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookview Healthcare Center 510 Thompson Street Gaffney, SC 29340

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46934

Residents Affected - Few Based on review of the facility policy, record review, and interview, the facility failed to report to the State Survey Agency (SSA) an alleged incident involving sexual abuse, that occurred on 02/04/25.

Findings include:

Review of the undated facility policy titled Abuse and Neglect Prohibition, documented, Prevention 2.) 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. The facility will report allegations and substantiated occurrences of abuse, neglect and misappropriation of resident property to the state agency and law enforcement officials designated by state law. The facility will report to the company management and legal departments in accordance with company reporting procedures. The facility will report any occurrences of abuse by registered or certified staff to the State Board as required by state law. Policies and facility procedure will be analyzed and modified as necessary by the QA&A Committee so as to meet the full intent of the law.

Review of Resident R1's HPI (History of Present Illness) dated 02/05/25, documented, [Resident R1] is a 77 y.o. a female who presents to the emergency department today given concerns over a potential sexual assault. History somewhat limited as patient does have a history of dementia, I am told by EMS that her care facility reported to the family that another individual with dementia may have exposed himself and had been on top her two days ago, the family had requested that she be transferred to the emergency department for further assessment .

Review of Resident R2's HPI dated 02/04/25, documented, PT to ED via EMS from Brookview. Facility states pt had Aggressive behaviors. Spoke with case management regarding the patient no longer being accepted at BrookView due to sexual assault against another [NAME] of BrookView.

Review of the Employee Statement Form written by Licensed Practical Nurse (LPN)1 on 02/04/25 at 1:00 AM, documented, On 2/4/25 at around 1 AM, . Staff was noted in room [ROOM NUMBER]. Particularly 157A

in [Resident R1's] room. This nurse noted [Resident R2] standing beside of 157A'a bed with no pants on. [Registered Nurse (RN)1] explained she saw [Resident R2] on top of [Resident R1] when she entered the room then [Resident R2] got up and got dressed.

This nurse notified the DON and called EMS to transport resident to the hospital. [Resident R1] was laying in bed on back. Upon inspection, resident noted to have brief intact, still adhered to both sides. The brief was pulled up

the front, with the brief creating a thong like appearance, within the labia majoria. This nurse removed the brief. No redness, injuries, or bruising noted to the vulva or vagina area. Resident denied pain to that area. EMS arrived and escorted [Resident R2] to ER.

Review of an undated Employee Statement Form written by RN1, documented, Upon walking onto Peach Unit, I heard water running in 157 and knew neither resident could turn it on. When I opened the door the water in the sink was on and about to over flow. I then saw [Resident R2] naked on top of [Resident R1]. I told him to get off of her right now. [Resident R1] was laying flat in bed with cover pulled off, gown pulled up and brief slightly pulled to the side. [LPN1] then called the DON and EMS.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 425062 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425062 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brookview Healthcare Center 510 Thompson Street Gaffney, SC 29340

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 0609 During a phone interview with the Ombudsman on 02/27/25 at 10:34 AM, revealed she is aware of the complaint involving Resident Resident R1 and Resident R2. The Ombudsman stated that Resident R1's daughter had contacted her to Level of Harm - Minimal harm or make a complaint and told her that the police were investigating the complaint. The Ombudsman stated she potential for actual harm could not recall the exact date; however, it was February 2025. The Ombudsman stated she came to the facility on [DATE REDACTED], and no one at the facility reported anything to her regarding the incident that occurred Residents Affected - Few between Resident R1 and Resident R2. The Ombudsman also stated she gave Resident R1's daughter the department's information to submit an online submission.

During a phone interview with Resident R1's Representative (RP) on 02/27/25 at 10:28 AM, revealed that on 02/05/25, between 10:30 AM and 11:00 AM, the Director of Nursing (DON) contacted Resident R1's RP via phone and said on Monday night 02/03/24, going into 02/04/25, Resident R2 was completely naked, and was actively trying to get Resident R1's brief off. The facility staff intervened and removed him from her room. Staff told her (Resident R1's RP) they didn't think that it was a big enough deal and since they didn't find anything, it was not a reportable offense.

During an interview, via phone, with LPN1 on 02/27/25 at 2:24 PM, LPN1 confirmed her statement. LPN1 stated she spoke to the DON, she and another nurse, and since her brief was intact, they didn't believe she was penetrated, or sexually assaulted which is why she was not sent to the hospital. LPN1 stated she spoke to the DON first, and informed she would take care of it all the following morning. LPN1 stated she did not notify Resident R1's family.

During an interview with the Director of Nursing (DON) on 02/27/25 at 12:19 PM, the DON stated she is aware of a situation between two residents, Resident R1 and Resident R2. LPN1 called her on 02/04/25 at 1:00 AM, stating RN1 located Resident R2 in Resident R1's room, completely naked, on top of the female resident. The female residents covers were pushed back, brief still on. There was no evidence that he penetrated her, no redness, no discharge, no bruises. The DON stated on 02/05/25, she called the daughter and apologized in regards to her not being notified the day it happened.

During an interview with the Administrator on 02/27/25 at 3:40 PM, the Administrator stated the DON told her that Resident R2 went into Resident R1 rooms, Resident R2 was found naked, at Resident R1's bedside. The Administrator stated the DON is responsible for reporting, and this incident should have been reported, and is unsure as to why the DON did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 425062