The resident at Arbor Glen Care Center told inspectors on April 10 that staff routinely took 30 minutes to answer her call light. When they did respond, they often promised to return but didn't come back for another 30 minutes, leaving her waiting a full hour for assistance with incontinence care.
"Staff would sometimes tell Resident 2 that Resident 2 needed to wait until staff finished their rounds before staff could change Resident 2," according to the inspection report.
The resident, admitted in March with end-stage renal disease and mobility problems, required substantial assistance with toileting and was frequently incontinent. Her care plan specifically noted she was at risk for falls related to incontinence episodes and required staff to anticipate her needs.
During the inspection, the resident pressed her call light at 4:27 p.m. because she needed a brief change. Inspectors watched as six staff members walked past her room while the call light remained activated and unanswered.
The light stayed on for nearly 10 minutes. At 4:36 p.m., the call light alert was announced over the facility's system and the light above her door illuminated. A minute later, the resident pressed the call button again.
When a certified nursing assistant finally arrived at 4:38 p.m., she 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 interviews with staff revealed a dysfunctional system where licensed nurses refused to help certified nursing assistants respond to basic resident needs.
CNA 2 told inspectors that licensed nurses "did not help with answering residents' call lights." During her 15-minute breaks or lunch periods, the licensed nurses wouldn't cover for her, even for simple requests like providing water, a comb, or changing television channels.
"CNA 2 stated it was frustrating when the LNs did not help with answering call lights," the report noted.
Another nursing assistant confirmed the problem. CNA 1 said licensed nurses "would not just help if the call light was going off" and instead "would put it on the CNAs to do all of it."
The facility's own Licensed Vocational Nurse contradicted her colleagues' practices. LVN 1 told inspectors that answering call lights "was everyone's responsibility" and residents should wait no more than one to two minutes for responses.
"LVN 1 stated it was important to answer the call light within 1 to 2 minutes because it could be a safety or emergency issue," according to the report. She said even if she wasn't assigned to a particular resident, she needed to respond if available because "residents were in the facility to get help."
The Director of Nursing agreed that all staff should answer call lights "as soon as possible so residents could get the residents' needs met." She acknowledged that long waits "could be upsetting to the resident" and confirmed that licensed nurses needed to respond to call lights.
The facility's own policy required staff to "answer the light/bell within a reasonable time" and respond to residents' requests. If unable to assist, staff were supposed to explain the situation and notify the charge nurse.
But the resident's experience revealed a different reality. When staff other than her assigned caregiver answered her call light, they would tell her to wait for her assigned staff member instead of providing assistance themselves.
The inspection found this failure put the resident at risk for skin breakdown and compromised her well-being. For someone with end-stage kidney disease who required substantial help with toileting and experienced frequent incontinence, delayed response to call lights meant prolonged exposure to waste.
The resident's care plan had identified her fall risk related to incontinence episodes, making prompt staff response even more critical. Instead, she faced a system where licensed nurses refused to help and certified nursing assistants were left to handle all resident requests alone.
Federal inspectors documented the violations under regulations requiring facilities to provide necessary care and assistance with activities of daily living for residents unable to perform them independently.
The resident, who had intact cognitive abilities, could clearly communicate her needs and understand the delays she experienced. Her account of routine 30-minute delays followed by additional 30-minute waits painted a picture of systematic neglect of basic care needs at the Glendora facility.
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.