The incident occurred August 22, 2025, when resident 103 was awakened by tugging at his hip. The aide told him he had to remove his underwear but never announced himself or knocked on the door before entering the room.
"I was asleep and felt tugging at my hip," the resident told inspectors in January. "He said that I had to take my underwear off. He did not touch me sexually or anything but he didn't announce himself and he didn't knock on the door."
The resident had been admitted three days earlier with diagnoses including orthostatic hypotension and heart failure. His admission assessment showed intact cognition with a score of 15 on the cognitive evaluation.
Four days after the incident, the resident reported what happened to facility staff. He initially described it as an assault, saying the male aide "came into his room and assaulted him by pulling down his underwear." He then clarified it was his pants, not underwear, and said he had been "foggy since admitted from hospital" and that "medications have taken over his mind."
In a follow-up report the same day, the resident provided more details. He said he was "woken up by [the aide] was trying to pull my underwear down to get them off." The resident denied being touched inappropriately but said he didn't want the aide to care for him again. He didn't want police called and wasn't fearful.
The nursing assistant, identified as E16, "adamantly denied this allegation" when questioned three days later. He acknowledged caring for the resident but denied pulling down his underwear or assaulting him.
The facility's response was limited. On September 15, the director of nursing wrote to state regulators that the aide "was educated as to customer service explaining why you have entered the room and if you want check the patients for incontinence to let them know that."
No additional training followed.
"No follow up training was given to [E16] after the incident," the director of nursing told inspectors in January. "E16 only works every other weekend. When E16 returned the resident was already discharged from the facility."
The case illustrates gaps in basic dignity protocols at the facility. Federal regulations require nursing homes to treat residents with dignity during all care activities, including explaining procedures and obtaining permission before intimate care.
The resident's account remained consistent across multiple interviews spanning five months. He never alleged sexual contact but repeatedly emphasized the aide's failure to announce himself, knock, or explain the incontinence check before attempting to remove his clothing while he slept.
The aide worked part-time, every other weekend, which may have contributed to the facility's minimal follow-up. By the time he returned to work, the resident had already been discharged.
The facility's incident reports documented confusion about exactly what clothing the aide attempted to remove - underwear versus pants - but the core violation remained unchanged. Whether underwear or pants, the aide attempted to remove a sleeping resident's clothing without permission or explanation.
Federal inspectors found the facility failed to ensure the resident was treated with dignity when staff didn't wake him or obtain permission before attempting incontinence care. The violation affected few residents but represented what inspectors classified as minimal harm or potential for actual harm.
The resident's cognitive assessment showed he was mentally capable of understanding and consenting to care procedures. His clear recollection of events months later, despite initial medication-related confusion, supported his account of what happened that August morning.
The case was presented to facility leadership including the director of nursing, assistant director of nursing, nurse educator, and corporate educator during the inspection's exit conference on January 30, 2026.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Hillside LLC from 2026-01-30 including all violations, facility responses, and corrective action plans.