The September 29 incident at Pembroke Center left the woman crying in her electric wheelchair until after midnight, when the next shift finally transferred her to bed and provided the care she needed.
Nursing assistants #4 and #5 were working the 3:00 PM to 11:00 PM shift when they entered the resident's room to help transfer her to bed around 10:30 PM. The resident cursed at them during the interaction. Both assistants then refused to provide any further care and left for the night without helping her.
Nurse #7, who was working the overnight shift, discovered the situation when she arrived at 11:00 PM. The resident was still sitting in her wheelchair, visibly upset and crying that she had been left up and needed incontinence care.
The nurse had been unaware that the two assistants planned to abandon their duties. She told inspectors the assistants reported the resident had cursed them, and she said she would speak to the resident about the incident. But the assistants never mentioned they were refusing to provide care before leaving their shift.
Making matters worse, one of the overnight nursing assistants was an hour late for work. With only two assistants assigned to cover both the 300 and 400 halls at night, the resident remained in her wheelchair until nursing assistant #7 and the late-arriving assistant #6 could transfer her to bed at approximately 12:30 AM.
The overnight nursing assistant told inspectors she found the resident "very upset and crying" about being left in her wheelchair. She and her colleague provided the needed incontinence care along with transferring the resident to bed, but not until nearly two hours after the evening shift had abandoned her.
Nursing assistant #7 explained she hadn't asked the nurse to help with the transfer because the nurse was busy with new admissions and other duties.
The Director of Nursing called the incident "unacceptable" during her November 18 interview with inspectors. She said she expected nursing staff to provide care for residents regardless of whether residents used curse words, explaining that providing activities of daily living care was simply their job.
The facility's Administrator echoed that position, telling inspectors that the two nursing assistants were wrong for not providing care to the resident. She said staff should provide assistance when residents request it, regardless of residents' behavior.
The inspection report doesn't detail what disciplinary action, if any, the facility took against the two nursing assistants who refused care. It also doesn't specify the resident's medical condition or mobility limitations that required assistance transferring from her wheelchair to bed.
Federal regulations require nursing homes to provide necessary care and services to help residents achieve their highest level of well-being. Staff cannot selectively refuse care based on residents' behavior or verbal outbursts, which can result from medical conditions, medications, or the frustration of institutional living.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. But for the woman left crying in her wheelchair with soiled incontinence protection, the impact was immediate and prolonged.
The incident occurred during a complaint investigation at the 310 E Wardell Drive facility. Federal inspectors completed their review on November 21, documenting the care refusal as a violation of quality of care standards.
The overnight nurse's account revealed systemic staffing challenges beyond the individual assistants' conduct. With just two nursing assistants covering multiple halls and one arriving an hour late, residents faced extended waits for basic care even when staff performed their duties properly.
For the resident at the center of this incident, what should have been routine bedtime assistance became hours of distress. She remained trapped in her wheelchair, soiled and crying, because two staff members decided their hurt feelings mattered more than her basic human dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pembroke Center from 2025-11-21 including all violations, facility responses, and corrective action plans.