Federal report: Sexual abuse occurred at Sweet Brook among cognitively impaired residents

The Centers for Medicare & Medicaid Services placed Sweet Brook Rehabilitation & Nursing Center in Williamstown in a state of "immediate jeopardy" of losing its funding after a March 12 survey showed that staff failed to prevent multiple instances of sexual and physical abuse between residents from December 2018 to February, according to a federal report.

WILLIAMSTOWN — As the Sweet Brook Rehabilitation & Nursing Center fights to keep its state license, a newly released federal report details alleged sexual abuse in recent months involving cognitively impaired residents.

The Centers for Medicare & Medicaid Services placed the Williamstown nursing home in a state of "immediate jeopardy" of losing its funding after a March 12 survey showed that staff failed to prevent multiple instances of sexual and physical abuse between residents from December 2018 to February, according to the report.

The facility was removed from the "immediate jeopardy" status March 31, but just over a week later, the Department of Public Health moved to revoke its license to operate.

"It's absolutely disgusting, that report," state Rep. John Barrett III, D-North Adams, said Wednesday. "If it isn't cleared up, I'm going to turn to the congressmen and senators and ask them to get involved, if need be."

On April 9, the DPH notified the facility, which is ranked in the bottom 1 percent of nursing homes in the state, that action was being taken against its license to operate.

The notice from the DPH detailing reasons for that action hasn't yet been made available through a public records request from The Eagle. The federal survey from the previous month details reports of abuse from December to February.

During that time period, Sweet Brook administrators called Williamstown Police twice to report alleged sexual contact between parties with diminished mental capacity, according to Chief Kyle Johnson.

On Feb. 7, one resident was found holding another resident's hand on top of their exposed genitals, forcing that other person to sexually gratify the aggressor, according to the report. The resident who was victimized in this incident is "severely cognitively impaired" and unable to make their own decisions, according to the documents.

In a statement, Sweet Brook owners said a plan they recently submitted in response to the March survey had been accepted and included steps "to assure resident safety."

"This included more supervision of our individual residents and their interactions with each other; we have taken steps to provide that," the statement said.

A nurse's note of one incident indicated that the abuse occurred in the day room, which was referred to in the report as the "man cave." When staff discovered the forced sexual contact, the "aggressor" resident wouldn't let go of the victim's hand, prompting an assistant to physically break up the interaction, according to the report.

The assistant told a surveyor that because of the victim's dementia, the person doesn't show emotions or verbally communicate.

The aggressor has since been put on a drug to limit their sexual impulsivity, according to the report.

"The facility failed to provide adequate staff supervision and monitoring in the man cave [day room] to ensure that at risk, vulnerable and cognitively impaired residents were protected and free from the potential for physical and or sexual abuse," the report said.

While staff encourages men at Sweet Brook to use the day room, including those with a history of sexually aggressive behavior, "there was no documentation to support that the facility provided any type of staff supervision to the man cave [day room] while any residents were in the room," the report said.

On Dec. 6, staff found the same aggressor receiving nonconsensual oral sex from a different resident in a room that neither of them lived in, according to the report.

For the two days prior, there were multiple incidents where the two had expressed inappropriate sexual behavior toward each other and the facility failed to address the behavior or prevent it from escalating, the report said.

A few hours after this was discovered, the individual performing oral sex said they had no memory of it. The recipient of the oral sex — the resident viewed as the aggressor — "remained upset throughout the afternoon and evening, repeatedly stating he/she had every right to get `some,' " the report said.

A social worker who was interviewed said that the behavior wasn't consensual because neither of the people involved has the mental capacity to consent.

Though staff was aware of the incidents, when surveyors reviewed the medical records of both residents, they found no documentation that the facility had assessed or monitored them afterward.

Aside from alleged sexual abuse, surveyors also learned of a series of physical altercations involving residents. One resident's face was slammed into a door frame, another was pushed, and another had been punched in the face.

History of care issues

It has been a year and a half since signs of neglect and abuse at the poorly rated nursing facility arose in the form of a federal Centers for Medicare & Medicaid Services (CMS) survey.

Agencies appeared to start taking note of serious issues at the facility in fall 2017. That September, after an inspection, the CMS placed the facility in a state of "immediate jeopardy," threatening to pull its funding after it discovered dozens of instances in which patients were mistreated, abused or neglected by staff.

The violations noted, among other things: the resuscitation of a patient without consent, leaving residents in soiled diapers and unsanitary restraints for extended periods, and verbal and financial abuse of residents wishing to leave the facility.

The violations prompted the CMS to temporarily freeze Sweet Brook's ability to admit new patients. That freeze was lifted in November 2017, after the facility corrected initial deficiencies and came back into compliance with federal regulations, the CMS said at the time.

But inspectors discovered additional violations when they returned in March 2018, though funding was not frozen at that time.

After that, nearly a year passed until the CMS, in February, put Sweet Brook on a list of "special focus" facilities, which is made up of fewer than 90 nursing homes across the country that have demonstrated long-standing issues in quality of care.

At that time, a spokeswoman for the facility said that the issues that prompted the federal agency to designate Sweet Brook a special focus case were over a year old and conditions had improved. Any remaining issues were being addressed by staff and outside consultants, the spokeswoman said at the time.

Then the March survey was released.

Barrett said he is upset that the CMS removed the facility from the "immediate jeopardy" status after what he termed the "terrible" findings in the survey.

"They should be ashamed of themselves, saying that all of the deficiencies were satisfied when this had been going on for three months," he said. "I am very confident that the state will not back down on this."

He said he expects that the DPH will not be as lenient when dealing with the facility.

On April 19, the DPH provided Sweet Brook with official notice of a license revocation, which included the specific grounds for the action.

The nursing home has 30 days from that notice to file an appeal. No appeal had been filed by Wednesday, a statement from the DPH said.

"Sweet Brook remains committed to maintaining our license and are pursuing all steps necessary to do so," Sweet Brook said Wednesday.

Sweet Brook is owned by Alexander, Rochelle and Samuel Sherman, as well as Jeffrey Goldstein and Zaleman Horowitz, according to the Centers for Medicare & Medicaid Services.

Federal and state public records show that members of this group have ownership interests in at least 16 facilities in Ohio and at least 13 in New York.

Haven Orecchio-Egresitz can be reached at horecchio@berkshireeagle.com, @HavenEagle on Twitter and 413-770-6977.