Arbor Glen Care Center: Residents Wait Hours in Soiled Diapers - CA
The resident's family member told federal inspectors they had observed this pattern "multiple times" — their loved one waiting 30 minutes to an hour for staff to respond to calls for help with soiled briefs.
When the physical therapist pressed the call light that morning to get the resident cleaned up for her session, nobody came. The resident told inspectors she "often had to wait a long time to get help from staff" and sometimes didn't even press her call light because she "was worried about bothering the staff because the staff was always so busy."
The scene at Arbor Glen Care Center illustrates the human cost of chronic understaffing documented by federal inspectors during their February 6 visit. One certified nursing assistant told inspectors she had been assigned to care for 18 residents the previous night — nearly double her usual load of 10 to 11 patients.
Assignment sheets showed the problem was systematic. On the night of February 5, five CNAs were responsible for 90 residents. Four of the five were assigned 18 residents each.
"It was difficult and unusual," the CNA said of her 18-patient assignment.
But the staffing crisis created more than delayed diaper changes. It bred a callousness that inspectors witnessed firsthand.
On February 6 at 4:10 PM, three CNAs were passing water from a cart in the hallway when a resident with Alzheimer's disease approached them in her wheelchair. The woman, who needed maximum assistance with basic tasks like sitting and standing, followed the staff down the hall pointing and saying "help, help."
One CNA turned to address her and said, "Not right now, I am busy." The aide then turned her back on the resident and continued distributing water.
When inspectors interviewed the other CNAs who witnessed this exchange, their responses revealed they knew it was wrong.
"I would not have turned my back from Resident 39," one said. "Resident 39 was confused and just wanted some assistance. I feel bad for Resident 39."
Another admitted: "I should not have told Resident 39 I'm busy. I should have asked another CNA to help Resident 39. Resident 39 deserved service, help, and dignity."
The facility's Director of Nursing agreed. "The facility should treat all residents with compassion and empathy," she told inspectors. "All residents should be treated with dignity, even the confused residents."
The facility's own policy on dignity and respect, revised just one month earlier in January 2025, stated that "all residents be treated with kindness, dignity and respect."
Beyond dignity violations, inspectors found serious infection control failures that put vulnerable residents at risk.
In the kitchen, staff were using sanitizing solution that tested at only 100 parts per million — half the minimum 200 ppm needed to effectively kill germs. The cook explained that too many washcloths in the sanitizing bucket had absorbed the disinfectant, reducing its potency.
"If the disinfectant was not at the correct strength, it may not effectively kill harmful microorganisms, like bacteria and viruses, that can spread between surfaces," the Director of Dining Services told inspectors.
The infection control problems extended throughout the facility. In a shared bathroom used by four residents, inspectors found unlabeled bottles of personal cleansers sitting on the sink — a violation that could lead to cross-contamination.
"Anything used for personal should always be labeled, not kept in public spaces or shared," the Infection Preventionist Nurse said. "I wouldn't want anybody using mine."
More troubling were the failures involving residents in isolation for dangerous infections. Three residents were housed together in one room — one with VRE in her urine, another requiring enhanced barrier precautions for medical devices, and a third with no isolation requirements.
Inspectors watched as CNAs repeatedly failed to change protective equipment between caring for different residents in the isolation room. One aide removed her gloves after caring for the VRE patient, then immediately helped set up breakfast for another resident without putting on new gloves. Another fed a resident without wearing any protective equipment at all.
"It was important to change PPE in between caring for residents in isolation for infection control and making sure the patients are safe," the Infection Preventionist told inspectors.
The violations extended to residents with the most dangerous infections. Two residents were in isolation for Candida auris, a deadly fungus that spreads easily and resists most antifungal medications. When a CNA entered their room carrying water pitchers, she wore no protective equipment despite the contact precaution signs on the door.
The aide told inspectors she "would wear a gown and gloves only when providing care" — not understanding that C. auris requires protection for any entry into the room.
"C auris would get passed easily," the Infection Preventionist explained.
The facility also failed to properly monitor antibiotic use for three residents, potentially contributing to the development of drug-resistant infections. Inspectors found that required surveillance forms to determine if residents met criteria for antibiotic treatment were either never completed or left incomplete.
"Any resident with an antibiotic order must have antibiotic surveillance to determine if they met the criteria and to deter the risk of antibiotic resistance," the Infection Prevention Nurse said.
Physical violations compounded the care problems. Inspectors discovered one room housing six residents — 50% more than the federal maximum of four residents per room. The administrator admitted he had added the sixth bed on January 20, 2025, and moved in the sixth resident the next day.
The facility had no policy limiting how many residents could be crammed into a single room.
In another room, inspectors found a resident's call light on the floor underneath his bed, completely out of reach. The resident had moderate cognitive impairment and required substantial assistance with daily activities and mobility.
"Call lights within reach enhanced the resident's safety and well-being as it allowed residents to quickly alert staff if they need assistance," a nurse told inspectors. "Call lights within the resident's reach helped prevent and reduced the risk of accidents, such as falls."
The violations paint a picture of a facility overwhelmed by its resident population and unable to provide basic dignified care. While administrators acknowledged their policies required adequate staffing and respectful treatment, the reality documented by inspectors showed residents sitting in their own waste, being ignored when they asked for help, and exposed to dangerous infections through poor infection control.
The resident who missed physical therapy because she sat in soiled diapers for two hours represents more than a single incident — she embodies a system failure that leaves the most vulnerable residents waiting for help that may never come.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ARBOR GLEN CARE CENTER in GLENDORA, CA was cited for violations during a health inspection on February 6, 2025.
When the physical therapist pressed the call light that morning to get the resident cleaned up for her session, nobody came.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.