The incident at Pavilion Of Waukegan occurred about two weeks before federal inspectors arrived for a complaint investigation in late October. The resident, who has lived at the facility for five years and is mentally intact, described how the aide's hands were "all over" her during what should have been routine shower assistance.
"I told the CNA I can do it myself," the resident told inspectors on October 27. "I have been here 5 years and only needed someone to help me with my back. The CNA's hands were all over me. I told the CNA to stop. The CNA said, take it easy."
The resident explained that previous staff had always provided privacy while she washed herself, with aides only helping with her back when needed. She now uses a back brush so no one touches her.
"When the CNA started washing me, I told the CNA to stop," she said. "The CNA thought I was being funny. I said, you are a sex maniac. You do not belong in the health field."
The aide involved, identified as V5, was not a regular worker on the resident's unit. She told inspectors she had been instructed by a nurse that she "cannot force the resident to take a shower" but explained that she uses redirection techniques with residents.
"I explained the rationale and R1 agreed," V5 said. "R1 is alert. R1 knows what is going on. If R1 did not want the shower, R1 would be resistive."
But the resident's account contradicts this version of events. She described getting herself dressed after the unwanted assistance and said she hasn't seen that particular aide since the incident.
"When I do it myself, I do not have to rush," the resident said. "I do not have to worry about being looked at. I feel I do a better job. I feel so good, so clean, I am happy."
Other staff members confirmed the resident's strong preference for independence during bathing. V10, a certified nursing assistant who regularly works with the resident, told inspectors the woman "can wash independently" and often gives herself sponge baths instead of taking showers.
"There have been times where I will go to get R1 ready for the shower and R1 has already completed the bath," V10 said. "R1 does not like to be touched by anyone, ever. R1 refuses the skin check, always."
The facility's own records support the resident's capability for independent bathing. Her Minimum Data Set assessment shows she scored 15 out of 15 on a mental status exam, indicating she is "mentally intact" with no upper or lower extremity impairments. Her shower needs were listed as requiring only "supervision with touch assist."
Despite living at the facility since 2019 and having a care plan focused on maintaining her self-care abilities, the resident's specific bathing and shower preferences weren't documented in her care plan until October 13, 2025. This was two days after the unwanted shower incident occurred.
The facility's care plan for the resident, dating back to March 2019, includes goals to "maintain current level of function" and interventions to "encourage the resident to use bell to call for assistance" and "praise all efforts at self-care."
Another aide, V9, told inspectors that staff policy requires them to be present in shower rooms with residents but allows residents to be "as independent as their ability allow." The goal, she said, is to "maintain the resident's functional ability."
The facility initiated an abuse investigation on October 13, two days after the incident. The investigation summary states that V5 "made (R1) feel uncomfortable when the CNA offered to help" and notes "the CNA was not aware of R1's showering preferences."
This explanation raises questions about staff communication and training. The resident had lived at the facility for five years with established bathing preferences that multiple regular staff members clearly understood. The incident occurred because a substitute aide from another unit wasn't informed about the resident's specific needs and preferences.
The resident's description of the encounter suggests more than simple miscommunication. Her account of telling the aide to stop multiple times, calling her a "sex maniac," and saying she didn't belong in healthcare indicates significant distress during what should have been routine personal care.
Federal regulations require nursing homes to honor each resident's preferences, choices, values and beliefs. The failure to communicate and respect this resident's well-established bathing preferences violated those requirements.
The resident's response to the incident was to become completely self-sufficient in bathing, using tools like a back brush to avoid any need for staff assistance. Her comments to inspectors reveal both the violation of her dignity and her determination to prevent it from happening again.
"In the past, the staff would provide privacy while I washed myself," she said. "The staff may have washed my back, now I have a back brush; no one is touching me again."
The incident highlights broader issues around resident autonomy and staff training in facilities. When a mentally intact resident with five years of established care preferences encounters an aide who ignores her explicit refusals, the breakdown represents both individual and systemic failures.
The resident's final words to inspectors captured both her distress and her relief at regaining control: "I feel so good, so clean, I am happy" when she bathes herself without unwanted assistance or observation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion of Waukegan from 2025-10-28 including all violations, facility responses, and corrective action plans.