Sexual Assault After Staff Ignored Red Flags
On April 1, 2025, a male resident was discovered with his hand inside the pants of a 72-year-old woman with severe dementia who had a cognitive score of just 1 out of 15, indicating profound impairment. The assault occurred after nursing staff observed and separated the two residents multiple times for inappropriate physical contact but then left them unsupervised.
According to the federal inspection report, Licensed Practical Nurse C observed the female resident "rubbing Resident #2's shoulder and trying to pull him close to her while grabbing his hand" at approximately 6:00 p.m. The male resident, who had moderate cognitive impairment but understood right from wrong, was told three times by staff that the woman was not alert and oriented and that he should not allow the behavior.
Over the next 30 minutes, staff separated the residents repeatedly. The woman attempted to sit on the man's walker. They were observed holding hands. Each time, nurses intervened and explained to the male resident why the contact was inappropriate, and he voiced understanding.
Despite these escalating warning signs, at 6:30 p.m., LPN C left the dining area to perform blood glucose monitoring on another resident. When she returned at approximately 6:55 p.m., both residents were missing from the dining area.
Discovery in Resident's Room
Two nurses found the residents in the male resident's room in a disturbing scene. The female resident was "lying in his bed on her back fully clothed with her pants unbuttoned and her zipper down while Resident #2 stood to the right of her fully clothed with his right hand inside of Resident #1's pants," according to witness statements. When the male resident saw the nurses, he quickly pulled his hand out of her pants.
The female victim had documented severe cognitive and behavioral challenges. Her medical records showed diagnoses of metabolic encephalopathy, dementia with agitation, schizoaffective disorder, and a history of extreme behavioral episodes. She had previously pulled out her PICC line and Foley catheter, attempted to bite and kick staff members, and required extensive psychotropic medications including multiple antipsychotics and benzodiazepines.
Just days before the assault, on March 24, the facility had actually increased her monitoring after violent episodes. She was initially placed on one-to-one supervision on March 7, which was downgraded to 30-minute checks on March 19. However, documentation shows no monitoring records were maintained between March 19 and April 1, when she was finally returned to one-on-one care after the assault.
Facility Mishandled Investigation
The facility's response to the assault revealed systemic failures in their investigation and reporting processes. Initially, the Administrator claimed the allegation could not be verified. He provided conflicting witness statements and schedules that did not match.
During the federal inspection on April 7, the Administrator first stated there were no other witnesses beyond the assigned nurse. He then produced a witness statement from "LPN I" who allegedly conducted a phone interview but was not on the facility's employee roster. When questioned about the discrepancies, he claimed staff members went by different names.
Only after repeated questioning by federal inspectors did the Administrator contact the actual witness, LPN B, who confirmed she had entered the room simultaneously with LPN C and witnessed the male resident removing his hand from the female resident's pants. The Administrator then stated he would "close the investigation and substantiate the abuse allegation" - six days after the incident occurred.
Male Resident Transferred, Not Properly Assessed
Following the assault, the male resident was placed on one-on-one supervision for only five days before being transferred to a sister facility on April 6. Medical records indicate he had no psychiatric diagnoses or documented history of sexual behaviors prior to this incident.
When federal inspectors visited him at the sister facility on April 8, he stated, "They transferred me here a few days ago. I did not have a choice." The receiving facility's staff confirmed they were told the female resident had initiated the contact, and consequently, they did not implement any sexual behavior monitoring or care planning for him.
The male resident's cognitive assessment showed he scored 12 out of 15 on mental status testing, indicating moderate impairment but sufficient understanding to comprehend the inappropriateness of his actions. A physician's note from April 2 stated he "appeared to be slightly confused but is aware of inappropriate behavior" when counseled about the incident.
Pattern of Inadequate Supervision
The inspection revealed broader failures in the facility's supervision protocols. Despite the female resident's documented history of severe behavioral issues and cognitive impairment, supervision levels were repeatedly downgraded without proper assessment.
Her care plan, initiated April 1 after the assault, noted she had a history of "making inappropriate sexual advances to other residents, aggression and other inappropriate behaviors." Yet between March 19 and the date of the assault, no frequent monitoring was documented despite physician recommendations for continued 30-minute behavior checks.
The facility's Quality Assurance Committee failed to identify or address these supervision gaps. Federal inspectors noted the committee "failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes."
Immediate Jeopardy Declared
Federal inspectors declared an Immediate Jeopardy situation on April 7, 2025, finding that the facility's failures placed all vulnerable female residents at risk for potential sexual abuse. The jeopardy level indicates the most serious type of violation that poses immediate risk to resident health and safety.
The inspection found multiple system failures contributed to the assault. Staff observed clear warning signs of escalating inappropriate contact between a cognitively intact male and a severely impaired female but failed to maintain supervision. The facility then mishandled the investigation, initially claiming the incident could not be verified and failing to properly interview witnesses.
Medical experts emphasize that residents with severe cognitive impairment scores like the victim's 1 out of 15 lack capacity to consent to any sexual contact. Such profound impairment means the person cannot understand the nature of the acts, cannot make informed decisions, and cannot protect themselves from exploitation.
The federal report indicates the facility lacked proper protocols for managing residents with sexual behaviors, failed to maintain adequate supervision levels based on assessed needs, and did not have functioning surveillance cameras that could have provided evidence. These systemic failures created an environment where a vulnerable resident with severe dementia could be sexually assaulted despite staff awareness of risk factors.
The facility must now submit a comprehensive correction plan addressing these deficiencies or face potential termination from the Medicare and Medicaid programs. The full inspection report details additional violations related to infection control, medication administration, and quality assurance processes that contributed to the unsafe environment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University East Rehabilitation Center from 2025-04-08 including all violations, facility responses, and corrective action plans.
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