The case is about a 79-year-old cognitively impaired woman allegedly sexually assaulted multiple times at Windsor Healthcare Center of Oakland, according to legal documents. The facility is located along Fruitvale Avenue.
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"This really strikes at the heart of the fundamental obligation of nursing homes -- keep your patients safe," said Ed Dudensing, a former Deputy District Attorney.
Pictures of bruises on Cheryl Doe, the former patient, were shared with the I-Team. She and her son, Robert, allege the injuries are a result of a sexual assault that was swept under the rug. Both are kept anonymous to protect their privacy.
Robert told the I-Team he admitted Cheryl with hopes to keep her safe as she battles Alzheimer's and dementia. But he says the real battle came with her care.
"The first time was rape....assault and I didn't find out until two days later after it initially happened," Robert told ABC7's Stephanie Sierra.
Robert says his mom was raped by another resident living in the facility last August. He says a certified nursing assistant told him about the assault, not management at the facility.
"She the CNA says your mom has been getting raped...in this facility... and they know about it. And they chose not to tell you," Robert said.
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According to the complaint, a CNA and a charge nurse knew about the alleged assault, but nothing was done. The complaint also says the facility denied it, but later acknowledged an employee witnessed it happen. Robert says several days after the first incident, the man was able to get back into her room and attack again.
"He retaliated against my mom and hurt her again...she went and told one of the nurses," Robert said. "He hit her... he beat her....there were bruises all over her arm and scrapes on her knee."
Elder abuse attorney Ed Dudensing is representing Cheryl and Robert. He says they're still in the preliminary stages of their investigation.
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"There was an individual who was residing at the facility, who was repeatedly sexually assaulting Cheryl," Dudensing said.
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"How many people at this facility do you think were aware that this was going on?" Sierra asked Robert.
"A lot of them," he said.
According to the complaint, two employees were specified.
Legal documents say after Cheryl was allegedly raped twice, there was an indication of it identified on her medical chart days later.
The I-Team spoke to an employee working at the facility during that time.
"One of my colleagues walked in on the assault... she saw the man on top of her. The other employees were trying to sweep it under the rug... I encouraged her to tell Robert," the employee told the I-Team.
For the past several weeks, the I-Team made efforts to reach Windsor Healthcare Center of Oakland for comment, but haven't heard back. It's part of a chain of skilled-nursing facilities operated by Brius Management Company, among other affiliates.
"They have a history of failures of care that not only involves resident on resident abuse, like this case, but other areas of neglect as well," Dudensing said.
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In 2018, the Centers for Medicare and Medicaid Services fined the facility for failing to be in compliance with Medicare requirements and determined its deficiencies caused actual harm to one of its residents
"We know these nursing home operators, especially the large ones, like the one involved here... they respond to their pocket book," said Dudensing. "And so we try to hold them accountable in that way."
According to the complaint, "Numerous red flags put the corporate defendants on notice of serious problems at their facilities, including Windsor Healthcare. Brius facilities have been the target of multiple civil lawsuits as well as state regulatory actions arising from resident injuries, sexual assaults, felony abuse, and resident deaths resulting from their deliberate and habitual understaffing of facilities and abject failures to ensure resident safety."
"Often, it's because of lack of staffing, you have lack of supervision, and these types of things happen," Dudensing said.
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Legal documents also stated there were numerous concerns raised that the level of staffing at Brius was inadequate.
"The defendants knew Windsor Healthcare was troubled, but kept admitting new residents without increasing staffing and hid the problems from prospective families, including Cheryl's family," the complaint said.
"She's an elderly woman, she doesn't deserve to be done like that," Robert told the I-Team.
Cheryl was removed from the facility after her son says he learned of the second alleged assault.
Take a look at more stories by the ABC7 News I-Team.