Height Street Skilled Care failed to answer call lights promptly for residents who needed basic assistance, federal inspectors found during an August complaint investigation.
Resident 1 has hemiplegia and muscle weakness affecting his left side, along with bowel and bladder incontinence. His care plan specifically requires staff to clean his peri-area with each incontinence episode due to his inability to control his bladder and rectum.
During an interview on August 28, Resident 1 told inspectors the night nurses were not supportive and didn't answer his call light. He said he felt ridiculed and helpless because nurses had taken hours to respond when he needed his brief changed.
The resident scored 15 on his cognitive assessment, indicating he was mentally intact and fully aware of the delays in his care.
Resident 2 faced similar neglect when requesting water. She told inspectors it took a long time for staff to answer her call light, with waits stretching to 45 minutes at night when she asked for something as basic as water.
Like Resident 1, she was cognitively intact with a perfect score of 15 on her mental status evaluation.
The facility's own policy requires nursing staff to "answer call bells promptly, in a courteous manner" and to "return to resident with the item or reply promptly." The policy, dated October 2022, sets clear expectations that staff apparently ignored.
When confronted with the residents' accounts, the Director of Nursing acknowledged the problem. During a September interview, she admitted that a 45-minute or hour-long wait was not acceptable when residents needed brief changes or water.
The delays had serious implications beyond mere inconvenience. Resident 1's care plan identifies him as having "ADL self-care performance deficit" related to his hemiplegia, impaired balance and limited mobility. His inability to perform basic tasks like toileting makes him entirely dependent on staff response to his call light.
Federal inspectors found that the facility's failure to answer call lights timely had "potential for delay in care and needs not addressed promptly." For residents with incontinence and mobility issues, such delays can lead to skin breakdown, infections, and psychological distress.
The violation affected multiple residents, though inspectors classified the harm level as minimal. However, for residents like the man waiting hours in a soiled brief or the woman denied water for nearly an hour, the impact was deeply personal.
Resident 1's medical conditions make him particularly vulnerable to the consequences of delayed care. His hemiplegia affects his non-dominant left side, while additional diagnoses include abnormalities of gait and mobility that prevent him from meeting his own basic needs.
The inspection report provides no indication that Height Street Skilled Care has addressed the systemic problem that left vulnerable residents waiting for fundamental care. The facility's policy existed on paper but failed in practice, leaving cognitively intact residents fully aware they were being ignored in their moments of greatest need.
For Resident 1, the hours spent waiting in soiled clothing while paralyzed on one side represented more than a policy violation. It was a failure of basic human dignity that left him feeling ridiculed by the very people tasked with his care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Height Street Skilled Care from 2025-08-28 including all violations, facility responses, and corrective action plans.