Federal inspectors documented the December 16 incident during a complaint investigation at the Perry Highway facility. Resident R149's call light went on at 9:29 a.m. and remained unanswered until 9:45 a.m., when two nursing aides finally responded.
The resident suffers from hepatic encephalopathy, a condition where liver dysfunction impairs brain function. She also has diabetes and morbid obesity, according to her clinical record.
Call bell audit records revealed a pattern of delayed responses to the same resident's room. On December 11, staff took 21 minutes to answer her call for help. The following day, December 12, the response time was 20 minutes.
During an interview on December 16, Registered Nurse Employee R12 confirmed that the facility had failed to accommodate Resident R149's call bell needs.
The inspection report provides no details about what the resident needed during those extended waits or how the delays affected her condition. Federal regulations require nursing homes to reasonably accommodate residents' needs and preferences, including prompt responses to requests for assistance.
Hepatic encephalopathy can cause confusion, disorientation, and changes in consciousness. Patients with this condition may have difficulty communicating their needs clearly or understanding why help is delayed.
The facility's own audit system captured the problem across multiple days, documenting response times that stretched well beyond acceptable standards. Yet the pattern continued even as administrators tracked the delays.
Highland Hills Post Acute operates as a post-acute care facility, typically serving residents who require rehabilitation services after hospital stays. These patients often depend heavily on nursing staff for assistance with basic needs, medication management, and monitoring of their medical conditions.
The December 19 inspection was conducted in response to a complaint. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
No information was provided about what steps the facility has taken to address the call bell response delays or prevent similar incidents. The inspection report does not indicate whether other residents experienced similar delays in receiving assistance.
The case highlights a fundamental aspect of nursing home care: residents' ability to summon help when needed. Call bell systems serve as lifelines for people who cannot independently address their medical needs, personal care requirements, or emergency situations.
For Resident R149, the combination of liver-related brain dysfunction and extended waits for assistance created a particularly concerning situation. Her medical conditions require careful monitoring and prompt response to changes in her status.
The facility's audit trail showed staff were aware of the problem. The documented response times of 16, 20, and 21 minutes occurred over a span of just five days, suggesting either inadequate staffing levels or poor response protocols.
Federal inspectors found that Highland Hills Post Acute violated Pennsylvania state regulations governing licensed facilities' responsibilities, resident care policies, and nursing services. The citations reference specific sections of Pennsylvania Code that mandate appropriate accommodation of residents' needs.
The inspection report notes that few residents were affected by this particular deficiency, though it provides no details about whether similar response delays occurred in other areas of the facility or with other residents.
Resident R149's case illustrates the vulnerability of nursing home residents who depend entirely on staff responsiveness for their safety and care. Twenty-one minutes can feel like an eternity to someone experiencing a medical emergency, pain, or urgent personal need.
The facility must submit a plan of correction to address the deficiency and prevent future occurrences. However, the inspection report provides no timeline for implementation or details about proposed solutions.
Highland Hills Post Acute's failure to respond promptly to call bells represents a basic breakdown in resident care. For someone with hepatic encephalopathy, those extended waits without assistance could compound confusion and anxiety already caused by her underlying medical condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Hills Post Acute from 2025-12-19 including all violations, facility responses, and corrective action plans.