F0610

G

Failure to Remove Alleged Perpetrator After Sexual Abuse Allegation Resulting in Second Resident Abuse

Concord, California Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and protect cognitively intact residents from alleged sexual abuse by a CNA, and to remove the alleged perpetrator from resident care after the first allegation. One resident, admitted with a left lower leg fracture and generalized muscle weakness and assessed with a BIMS score of 15 (cognitively intact), reported that during an evening incontinence care episode, a male CNA repeatedly wiped her vaginal area despite the brief being only wet with urine. She stated that the CNA wiped deeper between her labia and rubbed his finger within her clitoris, and that she told him to stop and that it was not okay. She usually required barrier cream but specifically declined it from this CNA and wanted the care to end. Later that evening, she told a familiar CNA that she had been inappropriately touched and asked who she could report it to; that CNA said he would inform the nurse. She then told an RN that she had been inappropriately touched by the CNA and that she never wanted him to change her again, but the RN did not ask further questions, focusing instead on ensuring the next shift knew she did not want that CNA assigned.

The following early morning, the same resident, described as emotional, reported the incident again to an LVN, clearly stating that the brief contained only urine and that the CNA had repeatedly wiped her and wiggled his finger in her vagina. The LVN reported this to the nurse supervisor (an RN), who then visited the resident later that morning and heard a consistent account that the CNA had excessively wiped her vaginal area and penetrated her with his finger. The RN reported this to supervisory staff, including the Director of Staff Development and indicated that the Administrator would be notified. However, the Assistant DON later characterized the resident’s complaint as a “customer care complaint” and focused on the resident’s request not to have the CNA assigned to her, after confirming with the RN that the resident had reported rough incontinence care and requested not to be cared for by that CNA. Despite the resident’s clear allegations of sexual abuse and multiple reports to different licensed nurses, the CNA remained on the staffing schedule and continued to work resident care shifts.

Staffing records show that the CNA worked the 2:45 p.m. to 11:15 p.m. shift on the date of the first alleged incident and then worked both the 6:30 a.m. to 3:00 p.m. and 2:45 p.m. to 11:15 p.m. shifts the following day, indicating he was not removed from resident contact after the initial allegation. During this time, a second cognitively intact resident, admitted with hemiplegia and hemiparesis following a non‑traumatic intracerebral bleed and with a BIMS score of 14, reported that the same CNA sexually abused her during a scheduled shower. She stated that when the CNA removed her sweater, he rubbed her breast, and she pushed his hand away and told him to stop. In the shower, she reported that he again attempted to wash her breast area with a washcloth, prompting her to request the washcloth so she could clean that area herself. She could not reach her buttocks, so the CNA washed that area from behind while she sat on a shower chair; she demonstrated that he inserted his finger into her anus. She further reported that after the shower, when drying her chest, he squeezed her nipples, leaving her feeling nervous during and after the event. She reported this to another staff member the next day. The facility’s abuse policy required immediate reporting to the administrator, protection of residents, and placing any employee accused of abuse on leave with no resident contact until the investigation was complete, but the CNA was not removed from duty after the first allegation, which allowed him to continue providing care and led to a second resident’s report of sexual abuse.