DELAND, FL - Federal inspectors documented serious supervision failures at University East Rehabilitation Center after staff discovered two residents in a compromising situation, leading to immediate jeopardy citations and intervention by state health authorities.
Critical Supervision Failures Led to Incident
On April 1, 2025, staff at University East Rehabilitation Center discovered a male resident with his hand inside a female resident's unbuttoned pants while she lay in his bed. The incident occurred despite multiple warning signs observed by nursing staff throughout the evening, including the residents holding hands, physical contact, and the female resident attempting to sit on the male resident's walker.
Licensed Practical Nurse C reported separating the two residents multiple times between 5:30 p.m. and 6:00 p.m., explicitly informing the male resident that physical contact was inappropriate given the female resident's cognitive impairment. However, when both nurses left the area around 6:30 p.m. to attend to other duties, the residents were unsupervised. Staff did not locate them until approximately 6:55 p.m., when they found them together in the male resident's room.
The female resident, identified in records as Resident #1, had severe cognitive impairment with a Brief Interview for Mental Status score of just 1 out of 15 possible points. Her medical record documented multiple psychiatric conditions including dementia, schizoaffective disorder, and metabolic encephalopathy. She required assistance with personal care and displayed aggressive behaviors toward staff.
Inadequate Monitoring Despite Known Risks
Federal regulations require nursing facilities to protect residents who cannot consent to sexual activity due to cognitive impairment. Individuals with severe dementia lack the mental capacity to provide informed consent for intimate contact, making them vulnerable to situations they cannot properly evaluate or refuse.
Inspection records revealed that Resident #1 had one-on-one monitoring discontinued on March 7, 2025, and replaced with 30-minute behavioral checks. However, even this reduced supervision was discontinued on March 19, 2025, leaving no documented increased monitoring protocol in place from March 19 through April 1, despite ongoing behavioral concerns including aggression, wandering, and the resident pulling out her own PICC line and urinary catheter.
The male resident, Resident #2, had intact cognition with a BIMS score of 12 out of 15 points and no documented history of psychiatric conditions or inappropriate sexual behavior. Nursing staff confirmed he was "alert and oriented" and typically compliant except for dietary restrictions.
Delayed Response and Insufficient Corrective Action
Following the incident, facility leadership implemented one-on-one supervision for Resident #1 but discontinued enhanced monitoring for Resident #2 after just five days. The Administrator confirmed that supervision was removed because staff determined Resident #1 had "initiated the sexual behavior."
This reasoning demonstrates fundamental misunderstanding of consent capacity. When an individual cannot consent due to cognitive impairment, the responsibility falls on staff to prevent situations where vulnerable residents can be placed at risk, regardless of who appears to initiate contact.
Resident #2 was transferred to a sister facility on April 6, 2025. When inspectors interviewed staff at the receiving facility, they confirmed no behavioral care plan addressing sexual conduct had been established because they were informed "the other female resident initiated the sexual act."
Standard protocols require comprehensive behavioral assessments and care planning for all residents involved in sexual incidents, regardless of who initiated contact, to prevent recurrence and ensure appropriate boundaries and supervision.
Systemic Management Deficiencies Identified
Federal inspectors documented that facility leadership failed to convene an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting following the incident. When asked why no meeting occurred, the Administrator stated "there was no reason to do so."
QAPI protocols exist specifically to analyze serious incidents, identify system failures, and implement corrective measures. The facility's own policy, reviewed January 1, 2025, explicitly requires the organization to "take action to improve performance" when "improvement opportunities are identified through quality assessment activities."
Additionally, the facility's Medical Director reported he was never informed of the incident until contacted by inspectors on April 8, 2025—one week after it occurred. The Medical Director stated he should have been notified immediately as both the medical director and QAPI committee member.
Licensed Practical Nurse C, who witnessed the escalating interactions between the residents and discovered them together, reported she was not contacted by facility leadership about the incident until April 8, when the Administrator called to request her account after learning of the federal investigation.
Additional Issues Identified
Inspection findings also documented inadequate care planning, with behavioral interventions for Resident #1 not initiated until April 3, 2025—two days after the incident. Her care plan listed interventions such as "administer medications as ordered" and "cue, reorient and supervise as needed" but included no specific supervision requirements despite documented wandering, aggression, and unsafe behaviors.
Resident #1's spouse told inspectors his wife "was very modest" in her previous life and "would have been very upset" by the incident if she had retained cognitive capacity to understand what occurred.
The facility received immediate jeopardy citations for failing to ensure residents were free from abuse and neglect, requiring immediate corrective action to protect resident safety.
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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