Resident 233, who has heart failure and diabetes, soiled herself at 9 AM on February 6 and pressed her call button for help. The physical therapist who arrived for her scheduled appointment also pressed the call light when he found her condition. No staff member came to change her until 11 AM.
"Resident 233 often had to wait a long time to get help from staff," she told inspectors. She said she sometimes didn't press her call light because she worried about bothering staff who were "always so busy."
Her family member witnessed this pattern repeatedly, telling inspectors they observed Resident 233 waiting 30 minutes to an hour for soiled briefs to be changed on multiple occasions.
The staffing crisis reached dangerous levels the night before the inspection. Four nursing assistants were each assigned to care for 18 residents during the 11 PM to 7 AM shift, with five CNAs responsible for 90 residents total.
CNA 4, who worked that shift, called the assignment "difficult and unusual." The aide normally cared for 10 to 11 residents, which was "manageable."
"The facility was short staffed at times especially during the evening and night shifts," CNA 4 told inspectors.
The understaffing created a cascade of indignity that extended beyond delayed diaper changes. On the afternoon of February 6, inspectors witnessed three nursing assistants passing water from a cart in the hallway while Resident 39, who has Alzheimer's disease, followed behind them in her wheelchair.
"Help, help," Resident 39 called out, pointing down the hallway.
CNA 4 turned to face her.
"Not right now, I am busy," the aide said, then turned away and continued distributing water.
Resident 39 has generalized muscle weakness and needs maximum assistance with personal hygiene and transfers. Medical records show she lacks the capacity to understand and make decisions.
When confronted about the incident, CNA 6 expressed regret. "I feel bad for Resident 39," the aide told inspectors, adding that the resident "was confused and just wanted some assistance."
CNA 5 acknowledged the response was inappropriate. "I should not have told Resident 39 I'm busy," the aide said. "I should have asked another CNA to help Resident 39. Resident 39 deserved service, help, and dignity."
The Director of Nursing agreed the treatment violated basic care standards. "The facility should treat all residents with compassion and empathy," the DON told inspectors. "All residents should be treated with dignity, even the confused residents."
The facility's own policies require staff to treat residents with "kindness, dignity and respect" and maintain "adequate staff on each shift to assure that the resident's needs are met," according to documents revised as recently as January 2025.
Yet the reality described by staff and witnessed by inspectors painted a different picture. Resident 233's experience illustrated how staffing shortages create a domino effect of delayed care that can escalate from inconvenience to health risk.
For diabetic residents like Resident 233, prolonged exposure to waste can lead to skin breakdown and infection complications. Her two-hour wait in soiled conditions also prevented her from attending scheduled physical therapy, potentially affecting her mobility and recovery.
The inspection found that some residents, like Resident 233, began self-rationing their requests for help rather than advocate for basic hygiene needs. This adaptive behavior suggests the staffing crisis had trained residents to expect delayed responses to their most fundamental care needs.
CNA 4's description of the previous night's assignment load provides context for the indifferent responses witnessed by inspectors. When individual aides are responsible for 18 residents requiring substantial assistance with toileting, transfers, and personal care, even urgent needs compete for attention.
The federal inspection documented violations of dignity and adequate staffing requirements, finding that residents experienced both delayed hygiene care and dismissive treatment from overwhelmed staff members who acknowledged their responses fell short of basic human decency standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbor Glen Care Center from 2025-02-06 including all violations, facility responses, and corrective action plans.