S ome of the victims can't speak. They rely on walkers and wheelchairs to leave their beds. They have been robbed of their memories. They come to nursing homes to be cared for. Luis Gomez appeared to many to be the perfect nursing aide. He loved his job and went the distance for residents in his care. But now a different image has emerged: Gomez, who insists he is innocent, is accused of being a serial abuser -- moving from facility to facility despite a history of allegations against him.
CNN documents his trail. The unthinkable is happening at facilities throughout the country: Vulnerable seniors are being raped and sexually abused by the very people paid to care for them.
It's impossible to know just how many victims are out there. But through an exclusive analysis of state and federal data and interviews with experts, regulators and the families of victims, CNN has found that this little-discussed issue is more widespread than anyone would imagine. Even more disturbing: In many cases, nursing homes and the government officials who oversee them are doing little -- or nothing -- to stop it.
Sometimes pure -- and even willful -- negligence is at work. In other instances, nursing home employees and administrators are hamstrung in their efforts to protect victims who can't remember exactly what happened to them or even identify their perpetrators.
In cases reviewed by CNN, victims and their families were failed at every stage. Nursing homes were slow to investigate and report allegations because of a reluctance to believe the accusations -- or a desire to hide them. Police viewed the claims as unlikely at the outset, dismissing potential victims because of failing memories or jumbled allegations.
And because of the high bar set for substantiating abuse, state regulators failed to flag patterns of repeated allegations against a single caregiver. It's these systemic failures that make it especially hard for victims to get justice -- and even easier for perpetrators to get away with their crimes. In fact, she was as vulnerable as an infant when she was raped.
The dignity which she always displayed during her life, which was already being assaulted so unrelentingly by Alzheimer's disease, was dealt a final devastating blow by this man. The horrific irony is not lost upon me Sonja Fischer is shown here in earlier days. She is pictured at top of this story during the last years of her life, with her daughter Maya's haunting quote.
Maya Fischer made this statement in court at the sentencing of a nursing assistant convicted of raping her mother. Choking back tears, Fischer detailed her mother's story -- recounting how she had fled Indonesia as a youth with her family to escape the rape and killing of young girls by Japanese soldiers, only to fall victim decades later to a man whose job was to care for her. A fellow caregiver saw male nursing assistant George Kpingbah in year-old Sonja Fischer's room at a. A bare leg was on each side of his hips, and her adult diaper lay open on the bed.
When the witness noticed the year-old aide thrusting back and forth, she said she knew a sexual assault was occurring. Kpingbah ultimately pleaded guilty to third-degree criminal sexual conduct with a mentally impaired or helpless victim and was sentenced to eight years in prison. In an emotional statement directed at Kpingbah during sentencing, the judge told him he had done more than ravage the lives of his victim and her family.
He had betrayed the public trust granted to caregivers who have such intimate access to the sick and elderly. It also affected everyone in that facility. Everyone who stays in that facility. Everyone who works at that facility. It affects everyone who has to place a loved one in a facility.
Kpingbah apologized at the hearing and said he planned to take his Bible with him to prison. His attorney asked for leniency. Kpingbah had endured his own personal struggles as a refugee, the attorney said, fleeing Liberia after many of his family members were killed.
Kpingbah's one "unspeakable act," he told the judge, was completely out of character. Yet in court documents uncovered by CNN, prosecutors revealed it wasn't the first time Kpingbah had been investigated over sexual assault allegations. Personnel records obtained by prosecutors during the investigation and reviewed by CNN show Kpingbah was suspended three times as Walker Methodist officials investigated repeated accusations of sexual abuse at the facility, including at least two where he was the main suspect.
The earliest complaint was in , when police investigated allegations he had engaged in sexual intercourse with a year-old who suffered from multiple sclerosis. In another case, an year-old blind and deaf woman who lived on the same wing as Fischer's mother said she was raped multiple times -- always at midnight. Police investigated her report just seven months before Fischer's mother was assaulted.
While the woman could not identify her assailant, Kpingbah was suspended by the facility along with several other male staffers who were on duty during the nights of the alleged assaults. None of these allegations were found to be substantiated by the facility or the state.
For years, Walker Methodist kept Kpingbah working on the overnight shift. Until that early morning in December , when someone caught him in the act. In that instance, the Minnesota Department of Health found that the facility acted immediately to ensure the resident's safety and promptly removed Kpingbah.
The state also noted that the facility had previously provided Kpingbah with required abuse training. As a result, the facility was not cited for any wrongdoing; only Kpingbah was held accountable for the assault. Walker Methodist refused to comment on the previous allegations against Kpingbah, who worked at the facility for nearly eight years, but said in a statement that it fully cooperated with authorities and that "the care and well-being of all of our residents and patients is our primary focus.
CNN reached out to family members of other residents who earlier reported they were sexually assaulted at Walker Methodist during the time Kpingbah worked there though he was not deemed a suspect in every case.
They said the officials there were quick to dismiss the residents' claims as hallucinations or fantasies. What should we investigate next? Email us. A son of a different alleged victim, who had accused an unknown perpetrator, said he was irate he was never told that a pattern of complaints had emerged against a single caregiver. Had he known of this pattern, the son said, he would have taken his mother's report of abuse more seriously. Instead, he trusted Walker Methodist. The Minnesota Department of Health told CNN it is barred by state law from releasing the identity of anyone investigated over an allegation that has not been substantiated, regardless of the number of allegations.
But both family members of these two alleged sexual assault victims also questioned the state health department. How effective is its oversight if it was aware of the multiple reports of abuse at Walker Methodist and still could not intervene? When pressed by CNN, the agency said that the reports occurred during a time when a paper system was used and that it has been working to modernize this system in the hopes of "flagging such patterns.
Some accounts of alleged sexual abuse come from civil and criminal court documents filed against nursing homes, assisted living facilities and individuals who work there. Other incidents are buried in detailed reports filed by state health investigators. A pound North Carolina nursing home resident who was so cognitively impaired she required assistance with even the simplest daily tasks reported that a nursing aide, behind closed doors, pushed her head toward him and forced her to give him oral sex.
The third time a resident of a Texas nursing home was raped by a nurse, the assailant ejaculated in the victim's mouth and on her breasts. When he left, desperate to hold on to whatever evidence she could, she spit the semen from her mouth into her bra and kept the unwashed bra for three weeks.
In Iowa, a woman who depended on a walker to move around and couldn't bathe herself reported that a nursing aide sexually assaulted her in the shower. But the facility never flagged this accusation to authorities because the aide had left the country.
But when CNN obtained the entire case file for a nursing aide convicted of raping an elderly stroke victim, we were able to do just that. As she began digging into the rape charge against nursing aide George Kpingbah, she uncovered a history of sexual assault allegations against him, and a name change that complicated her investigation. She requested all reports of sexual abuse from the facility where Kpingbah worked, Walker Methodist Health Center.
He was not linked to all of them by the facility but she wanted to see a complete picture of allegations made while he worked there. He requested the night shift. He applied for the job under a different name, Samuel Roberts, but records show he later changed his name to George Kpingbah -- a change the facility was aware of.
Dunlap was never able to determine the reason for the change. In his job interview, Kpingbah then Roberts said he liked caring for elderly people and that he had worked the night shift at other facilities, as shown by these notes kept in his personnel file. A job description shows that his duties included regular bathing of residents, dressing and undressing them, foot and nail care, oral hygiene, diaper care, and assistance in moving them around the facility.
In April , Kpingbah then Roberts was investigated by Walker Methodist and police over allegations he had engaged in a sexual relationship with a year-old resident who suffered from multiple sclerosis.
She said he was her boyfriend, but her son told CNN years later she would not have been able to consent to any sexual activity given her condition. Facility investigation notes show the woman identified Kpingbah after being shown a series of employee photos. He appears in silhouette, the result of a poorly scanned image in the case file.
Shortly after she reported the alleged abuse, her son says Walker Methodist told him it could no longer handle taking care of her, and he was forced to find a new facility.
Walker Methodist would not comment about the previous allegations against Kpingbah. In September , Kpingbah was suspended again when a year-old resident on 5 Raines, a wing for residents needing some of the most intensive care, said that a black aide had put his fingers inside her while washing her during the night shift. All black aides were interviewed, but records show that Kpingbah, who worked on the wing, was the only one suspended. Internal documents show the facility focused its investigation on people who worked in her wing, 6 Gamble, which did not include Kpingbah.
In August , a dementia patient reported that a black man raped her the previous night. Two black male nursing aides were suspended during the investigation -- but not Kpingbah, who according to his work schedule had not been on duty that night.
Just a week after reporting she was raped, the resident passed away. In October , a resident with dementia reported that a black man molested her. Kpingbah was not considered a suspect because he did not work the night the facility determined was referred to by the alleged victim. He did work two nights later -- the night before she reported the incident. And while she never identified anyone -- including Kpingbah -- as the alleged perpetrator, her son told CNN he was irate he was never told that a pattern of complaints had emerged against a single caregiver.
Instead, he trusted Walker Methodist, which cited her history of past hallucinations and proceeded to increase her dose of antipsychotics. In December , an year-old resident reported being sexually assaulted by multiple employees -- including two male caregivers. The facility wrote that she did not have male caregivers at that time and that she had a history of delusions and false allegations.