The scene unfolded November 25 during a federal inspection at The Citadel at Saint Anne Place, where four residents described a pattern of neglect so routine that one threatened to keep turning his call light back on no matter how many times staff shut it off without helping.
R15 has no clock in her room, so she can only estimate how long she waits. "It takes a long time," she told inspectors. "It feels like at least 20-30 minutes most of the time. It is worse during shift change or when they are on their breaks."
She lies in wet diapers regularly. Staff members walk into her room, turn off her call light, promise to return, and sometimes never come back. "It is not good," she said. "Some are very nice and others are not. Some do not want to listen to what I want them to do."
One aide threatened to abandon her entirely. "One girl yesterday threatened to leave the room and not come back."
R16 sometimes waits an hour for help. "Sometimes I wet my pants because I have to wait so long," he said. "Makes me feel helpless. Nighttime I think is the worst."
He's developed his own resistance strategy against staff who shut off call lights without providing assistance. "They are really good at turning off the call lights," he said. "I tell them as many times as they turn them off, I will turn it back on."
R17's IV machine became the soundtrack to systemic neglect. When inspectors arrived at 11:45 AM, he reported waiting anywhere from 15 minutes to two hours for help. The IV had been beeping for half an hour. A nurse promised to set a timer on her watch to remember to silence it.
The machine kept beeping.
At 12:15 PM — 30 minutes later — inspectors finally reported the continued alarm to nursing staff.
R17 has a catheter and stoma, so bathroom emergencies aren't his primary concern. He needs pain medication and help repositioning in bed. When staff ignore his calls, "it makes me feel like I have no value, like my concerns and my needs are immaterial."
He was told that any nursing assistant walking past his room should check on him when his call light is on. "That never happens," he said. His doctor is searching for alternative placement.
R18 faces the starkest choice. His bathroom door displays a sign reading "Wait for the nurse, don't get up alone." But when call lights go unanswered, he attempts the trip himself rather than soil his bed.
"Sometimes the call light doesn't get answered at all and I try to make it to the bathroom on my own," he said. "It is either that or wet the bed."
The strategy carries obvious risks. "I have fallen a couple of times, and I am afraid it will happen again. But I have to go to the bathroom."
Even when he successfully navigates to and from the bathroom alone, the call light in there continues ringing for 15 to 20 minutes after he returns to bed.
He's warned staff about the consequences of delayed response. "I always tell them they are going to have a bigger mess to clean up if they don't come in time."
The facility provides residents with a rights pamphlet stating that "Your facility must provide services to keep your physical and mental health, and sense of satisfaction."
Federal inspectors found the facility failed to ensure residents were treated with dignity by answering call lights promptly. The violation affected all four residents reviewed for dignity issues during the inspection.
R15 continues lying in wet diapers, uncertain of time's passage in her clockless room. R16 persists in his call light battle with staff. R17's doctor searches for a new facility while medical equipment alarms echo unanswered through hallways. R18 weighs dignity against safety each time his bladder fills, knowing that waiting for help might mean waiting forever.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Citadel At Saint Anne Place from 2025-11-25 including all violations, facility responses, and corrective action plans.
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