F0600

G

Failure to Protect Cognitively Intact Residents From Sexual Abuse by CNA During Personal Care

Concord, California Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The facility failed to protect cognitively intact residents from sexual abuse during the provision of personal care by a CNA. Resident 1, admitted with a left lower leg fracture and generalized muscle weakness and with a BIMS score of 15, reported that during an evening diaper change her brief was only wet with urine. She stated that CNA 1 stood on the left side of her bed and used wet wipes to clean her vaginal area multiple times. When she flinched, CNA 1 asked if it hurt, then wiped again, going deeper between her labia and rubbing his finger within her clitoris. Resident 1 reported that she told CNA 1 to stop and that it was not okay, declined her usual barrier cream because she wanted the care to be finished, and later documented the incident in four pages of personal notes she kept at her bedside.

Later that evening, Resident 1 told CNA 2 that she was uncomfortable with CNA 1 and did not want him to change her again. CNA 2 confirmed that he worked that afternoon, that Resident 1 appeared uncomfortable when discussing the diaper change, and that she stated she did not want CNA 1 to return to provide care. Resident 1 also spoke with RN 1 during medication administration and stated she did not like CNA 1 and did not want him to change her diaper again. On the following night shift, LVN 1 encountered Resident 1 during medication pass and observed that she was emotional. Resident 1 told LVN 1 that she had reported sexual abuse to two staff members and felt that nothing had happened. She clearly described that her diaper had only urine and that during the diaper change CNA 1 repeatedly wiped her and at one point touched and wiggled his finger in her vagina. RN 2 later interviewed Resident 1 and reported that she appeared distressed and tense and recounted that CNA 1 wiped her vaginal area excessively and penetrated her with his finger.

Resident 2, admitted with hemiplegia and hemiparesis following intracranial bleeding and with a BIMS score of 14, reported a separate incident of sexual abuse by CNA 1 during a scheduled shower. Resident 2 stated that CNA 1 took her from the patio to her room to prepare for the shower and, when removing her sweater, rubbed her breast. She reported that she swiped his hand away and told him to stop. While seated on a shower chair in shower room A, Resident 2 stated that CNA 1 again attempted to wipe her breast area with a washcloth, prompting her to request the washcloth so she could clean her own breasts. Because she could not reach her buttocks, she allowed CNA 1 to clean that area; she demonstrated that while he was behind her cleaning her buttocks, he inserted his finger into her anus. She stated she was shocked and told him she was done and to take her back to her room.

Resident 2 further reported that once back in her room, CNA 1 used a towel to dry her breast area and squeezed her nipples, and she felt nervous during and after the event. She stated she reported the incident to RNA 1 the next day. RNA 1 confirmed working that day, noted that Resident 2 appeared emotional and about to cry while recounting the shower experience from the previous afternoon, and verified from the staffing schedule that CNA 1 had assisted Resident 2 with her shower. Progress notes documented that Resident 2 informed staff that a male CNA who assisted with her shower had touched her inappropriately and that she was alert and oriented. An Ombudsman representative later interviewed Resident 2 privately and observed that Resident 2 became distraught and cried when recounting the events. The facility’s abuse, neglect, and exploitation prevention policy stated that residents have the right to be free from sexual abuse and that the program is intended to protect residents from abuse by anyone, including facility staff, underscoring that the described conduct by CNA 1 constituted a failure to protect residents from sexual abuse.