The resident told federal inspectors on April 10 that staff routinely took 30 minutes to answer her call light, then would promise to return but disappear for another 30 minutes. She said staff sometimes told her to wait until they finished their rounds before they could help with basic hygiene needs.
Inspectors watched the scenario unfold in real time. At 4:27 pm, the resident activated her call light requesting help changing her soiled brief. By 4:34 pm, six staff had walked past her room while the light remained on and unanswered.
The resident pressed the call light again at 4:37 pm.
Arbor Glen Care Center admitted the woman on March 4 with diagnoses including irreversible kidney failure, low blood sugar, muscle weakness and mobility problems. Her assessment showed she was frequently incontinent and required substantial assistance with toileting, bathing and dressing.
Her care plan specifically noted she was at risk for falls related to incontinence episodes. Staff were supposed to anticipate her needs and ensure her call light stayed within reach.
The facility's own nursing assistants said the delays were unacceptable. One told inspectors that residents should never wait more than five minutes for call light responses "because the residents may be in pain or may need something right away."
But a systematic breakdown in responsibility left residents waiting. Multiple nursing assistants complained that licensed nurses refused to answer call lights, even for simple requests like water or changing television channels.
"Sometimes when I would go on my 15-minute break or lunch break, the licensed nurses would not answer the call lights," one nursing assistant told inspectors. She called it "frustrating" when nurses ignored basic resident needs.
Another assistant said licensed nurses "would put it on the CNAs to do all of it" and wouldn't help unless specifically asked.
The facility's own Licensed Vocational Nurse contradicted this practice. She told inspectors it was "everyone's responsibility" to answer call lights within one to two minutes, regardless of assignments.
"Even if I was not assigned to the resident and I saw a call light on, I needed to answer it if I was available," the nurse said. She emphasized the urgency: "It could be a safety or emergency issue."
The nurse captured the fundamental issue: "Residents were in the facility to get help, so staff needed to help the residents because the facility was the residents' home and residents deserved to have their needs met."
The Director of Nursing agreed that all staff, including licensed nurses, must answer call lights promptly. She acknowledged that long waits "could be upsetting to the resident."
Yet the resident continued waiting. Her care plan promised she would "safely perform dressing, grooming, toilet use and personal hygiene with assistance." Staff were supposed to encourage her to "fully participate with each interaction."
Instead, she sat in soiled briefs while staff walked past her activated call light, sometimes being told to wait for her specifically assigned caregiver even when other staff were available.
The facility's policy stated that residents "unable to carry out activities of daily living will receive necessary services to maintain grooming, personal hygiene." The woman with kidney failure and frequent incontinence needed exactly those services.
She got a call light that nobody answered and promises that nobody kept.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbor Glen Care Center from 2025-04-11 including all violations, facility responses, and corrective action plans.