Some 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.
Instead, they are sexually assaulted.
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.
A daughter describes the resilience that helped her family not only heal but fight for reform.
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.
"At 83 years old, unable to speak, unable to fight back, she was even more vulnerable than she was as a little girl fleeing her homeland. 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 ... that the very thing she feared most as a young girl fleeing her homeland happened to her in the final, most vulnerable days of her life."
Maya Fischer made this statement in court at the 2015 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 83-year-old Sonja Fischer's room at 4:30 a.m. on December 18, 2014, at the Walker Methodist Health Center in Minneapolis. A bare leg was on each side of his hips, and her adult diaper lay open on the bed. When the witness noticed the 76-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.
"You violated (a) position of authority, a position of trust," Judge Elizabeth Cutter said at the sentencing hearing. "The ramifications of what you did are so far-reaching. ... 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 2008, when police investigated allegations he had engaged in sexual intercourse with a 65-year-old who suffered from multiple sclerosis. In another case, an 83-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 2014, 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.
Maya Fischer had no way of knowing about the previous allegations against Kpingbah uncovered by CNN. But she sued Kpingbah, who agreed to an unusual arrangement in which he is on the hook for a massive $15 million judgment only if he abuses again.
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.
"Walker Methodist certainly failed to handle this appropriately with my mother and other residents, and there should be consequences," said the son of the first alleged victim after learning of Kpingbah's rape conviction from CNN.
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."