(CNN) - It's the stuff of nightmares: Your loved one, who you thought was being well cared for in a long-term care facility or nursing home, was physically abused, raped or even impregnated. And you had no idea it was happening.
The family of a 23-year-old developmentally disabled women faced that horrific reality last February, after authorities discovered signs of sexual assault and a broken hip while she was living at a healthcare facility in Pensacola, Florida. The violent assault resulted in a pregnancy and later miscarriage, according to a lawsuit filed Thursday.
This latest attack follows the news of the "surprising" birth of a baby born last month to a 29-year old woman in a vegetative state in Phoenix, Arizona. According to a 911 call, staff at the Hacienda Healthcare facility had "no idea she was pregnant."
Should I worry about my loved one?
Millions of Americans have loved ones in long-term care facilities; millions more will face that choice soon. All are likely asking themselves: Is this something I should be concerned about?
"Unfortunately, this is something we should all be worried about, just as we have to worry about falls or bed sores," said elder abuse attorney Kirsten Fish. "These recent examples are extreme cases, but we're realizing this is an underreported crime that happens a lot."
An exclusive 2017 CNN investigation found the federal government has cited more than 1,000 nursing homes for mishandling or failing to prevent alleged cases of rape, sexual assault and sexual abuse at their facilities between 2013 and 2016. Nearly 100 of those facilities had been cited multiple times during the same three years.
That's likely just the tip of the iceberg. Experts say such abuse is not only under-reported and under-investigated, but often unnoticed or ignored.
"If they have any sign of mental illness, dementia or Alzheimer's, they could say, 'I was raped by so and so' but nobody believes them," said Pat McGinnis, executive director of California Advocates for Nursing Home Reform, a non-profit advocacy organization dedicated to improving long-term health care.
According to the National Consumer Voice for Quality Long-Term Care, women and men with dementia are most likely to be victims. They say resident-to-resident sexual aggression is the most common form of abuse in nursing homes, but perpetrators can also be temporary and permanent staff, family, friends, even complete strangers visiting the facility.
The 2017 CNN investigation also found most citations dealt with cases of residents abusing other residents. But the analysis also showed accusations made about aides, nurses and other staff members tended to be far more serious, involving allegations of forced intercourse, oral sex and other forms of sexual assault.
"It's a crime of opportunity," Fish said. "People who don't have friends or family to check on them at least monthly are most vulnerable to abuse. If there are staff shortages, which is common in the industry, there may be little supervision of the employees, especially at night."
Minnesota attorney Joel Smith, who specializes in representing those abused or injured in nursing homes, said it's not just one time of day or one caregiver, "it's shift after shift." He recommends that families investigate the quality of the facility's management.
"How does the place smell? Do people seem to care? If your heart is tugged at when you walk down the halls there's a good chance it is not [the] right place," Smith said. "The service you get on the front end reflects the quality of management behind the scenes."
Signs of sexual abuse
Experts say that families should be alert for signs of sexual abuse, even if the loved one doesn't -- or can't -- tell.
"The body speaks even though the mind or mouth cannot," Smith said.
Physical signs of abuse include bruising in genital areas, breasts and inner thighs, unexplained vaginal infections or bleeding, pain or irritation in the vaginal or anal areas, and torn, stained or bloodied underwear or linens. Also look for sudden or new difficulty walking or sitting, according to the National Consumer Voice for Quality Long-Term Care.
Not all abuse is visible, but there are other, possibly subtle signs as well. An abused loved one might withdraw from social activities and interactions, or develop sudden fears of the dark, increased nightmares or disturbed sleep. They could react differently to their abuser and show fear or avoidance of that person or a singular place. Panic attacks, extreme agitation and other PTSD symptoms could suddenly appear or grow worse. Some might even attempt suicide.
There is a national registry of Medicare funded nursing homes where you can find out how the facility ranks and if it has been cited in the last three years for sexual or other forms of abuse. Since few cases are reported, that may not tell you much.
Experts suggest families ask about staff training, frequency of check-ins and whether all staff, volunteers and vendors have had criminal background checks.
But Smith, who has prosecuted a number of abuse cases in which employees or facilities covered up abuse, is skeptical.
"If it's a bad facility, I don't have faith in the type of answers you will get," Smith said. "I feel like the people who run the bad facilities get really good at rebuffing legitimate questions."
Be aware of your loved one's rights, said McGinnis. Any nursing home or facility that receives funds from Medicare or Medicaid, and nearly all do, fall under federal law. The law says every 90 days every resident is supposed to get a medical exam, by a medical doctor or physician's assistant.
"In California, it's every 60 days for nursing homes," McGinnis said. "And the state just recently applied that to assisted living facilities. You also have a right to see your loved one's medical chart, and you should take advantage of that."
McGinnis also tells any family with a loved one in a nursing home certified by Medicare or Medicaid to start a family council and start sharing their experiences.
"Federal law says that when two or more relatives of nursing home residents get together, the facility has got to give them a place to meet," she said. "They've got to respond to the family council's recommendations or concerns within a certain time period. It's a very powerful tool."
Federal law clearly lays out the rights of residents and the responsibilities of the facility. If you feel those are not being met, reach out to your state's long-term care ombudsmen program [you can search by state online]. Funded by the government, the program provides advocates who can investigate complaints for residents in nursing homes, long-term care homes and assisted living facilities.
"When requested by the family, the ombudsman has the right to enter the care facility and investigate," Smith said. "While they can't arrest, they can go in and start waving shiny lights into dark places and hopefully uncover and solve problems."
Above all, if you are concerned about possible sexual abuse of your loved one, act. Call the ombudsman, call adult protective services, call local police and obtain immediate medical attention for your loved one.
"It's eternal vigilance," McGinnis said. "Until all care staff starts treating every resident as if they were their own mothers and fathers, I don't see it getting any better."
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