The Open Field Assisted Living facility in Tarboro is closed now after one patient was raped and another murdered last year, but an investigation into the deeper issues reveals a systemic problem that many adult care homes are facing.

Trenneth Axel Pace, 60, was charged with first-degree murder in the death of 75-year-old Rebecca Eudy in the spring of 2018. He also was charged in connection with the multiple rape of another 72-year-old patient at the facility who suffered from dementia.

According to comments from residents and staff members at Open Fields made publicly available through the state Division of Health Service Regulation, Pace, who is identified only as “Resident #3” in these records, was a known sex offender when he was admitted to the facility in March 2016.

The North Carolina Sex Offender Registry reveals that he was convicted in another state of strong arm rape of a 14-year-old and two counts of assault and battery of a child. His minimum registration period was “lifetime.”

Still, he was admitted to the facility.

Records also indicate that Pace was arrested on an assault charge in December 2017 in connection with an incident that happened at the Open Fields Assisted Living facility.

Still, he was allowed to remain at the facility.

Pace was diagnosed with schizoaffective disorder, bipolar type, among other issues. Reports from multiple interviews indicate that patients and staff were afraid of him because his verbal abuse and violent outbursts. On one occasion, he was reported for placing his hands down the incontinence brief of a patient with dementia and fondling her.

Still, he was allowed to remain at the facility.

Patients who complained were reportedly told to ignore him because his actions were related to “his diagnosis.”

On April 5, 2018, Eudy, who had reportedly been in a relationship with Pace and had ended it, went out on date with another man. She was “giddy and happy,” staff members said, when she came back from the date with a chocolate bunny and a soda from a fast-food restaurant, eager to share details about her outing with them, who noted that Pace was listening from the wings.

Staff members later said that Pace entered Eudy’s room. A few minutes later, Eudy’s roommate reported that there was “something wrong” with Eudy. They found her lying on the floor. She “did not have a pulse and her mouth was purple with dried blood around her mouth and nose,” according to interviews. When EMS arrived, they pronounced her dead and called authorities, noting that it was a suspicious death.

Eudy had been asphyxiated and suffered traumatic injuries to her neck from manual strangulation, according to her death certificate.

Pace was arrested on April 30, 2018, and charged with the forcible rape of another patient at the facility. On May 11, 2018, he was charged with Eudy’s homicide.

Pace was not the only patient with mental issues at the facility who threatened the safety of other patients. After an investigation of the facility, the state issued penalties of $70,000 against Open Fields, citing these incidents and multiple other charges of mismanagement, inadequate staffing and supervision, violation of patient rights and improper patient care.

The facility was shut down last summer, forcing roughly 100 residents to find other housing.

While many of these issues were problems with the way the facility was run, Open Fields’ failure to screen out Pace from the beginning is indicative of a larger problem in the state, said Deborah Coley, director of the Edgecombe County Office of Aging.

“One of the problems we have is mental health care,” Coley said. “There are not enough mental health facilities, so sometimes these people end up being placed in environments where they don’t belong.”

Finding placement for people with mental health issues is a growing challenge, she said.

“We are in a mental health crisis. A lot of them end up in jail, and their needs are not being met there. They don’t really belong in an assisted living facility, but where do they go? You have to find a bed for them. You have to find someone to take them,” Coley said.

Ashley Winstead, senior services supervisor for Nash County, agreed about the problem.

“When Dorothea Dix and some of the other mental health facilities in the state shut down, many of those people where stuck in other facilities and were not screened out. In some cases, the only other option was to stick these patients on the side of the road someplace,” she said.

Winstead said the problem is not limited to North Carolina.

“It has become a nationwide problem because these nursing homes and assisted living facilities are not equipped to deal with these older adults who are coming in with these mental health issues,” Winstead said. “We have a mental health crisis in America and that is what is sad.”

Nursing homes and assisted living facilities usually try to screen for patients with mental health issues, Winstead said, but, as Coley noted, facilities that are struggling financially are more willing to take them on. That decision can end in tragedy, as it did at Open Fields.

“There is a challenge as to how we meet the needs of all the people in the community,” Coley said.