Woodmont Center: Call Bell Safety Failures - VA
The resident, identified in the inspection report as Resident #6, told inspectors that staff do respond when she uses her call bell. But she explained the fundamental problem: "This can only happen when the call bell is within reach."
It wasn't.
At 3:37 p.m. that Sunday, inspectors found the resident lying in bed with her call bell on the floor beside her. The resident told them directly that "the call bell is not always within her reach."
Four minutes later, inspectors interviewed the licensed practical nurse assigned to the area. LPN #1 had retrieved the call bell from the floor and was holding it when inspectors spoke with her.
The nurse knew the protocol. She told inspectors that when a resident is in bed, "the call bell should be placed next to him or her or clipped on him or her, so the call bell is within the resident's reach."
She acknowledged what inspectors had documented. The call bell was not within the resident's reach.
Call bells represent the most basic safety mechanism in nursing home care. They serve as a resident's only means of summoning help for medical emergencies, falls, or urgent needs when staff are not present in the room.
Federal regulations require nursing homes to reasonably accommodate each resident's needs and preferences. The call bell requirement falls under this broader mandate, recognizing that residents must have reliable access to emergency assistance.
The violation occurred during a complaint investigation at the 11 Dairy Lane facility. Federal inspectors classify this as causing "minimal harm or potential for actual harm," but the implications extend beyond the single documented incident.
The resident's statement that call bells are "not always" within reach suggests a pattern rather than an isolated oversight. When residents cannot reach their call bells, they become effectively isolated from help during medical emergencies or urgent situations.
Licensed practical nurses undergo specific training on patient safety protocols, including proper call bell placement. The nurse's accurate recitation of policy to inspectors - while holding a call bell that should have been clipped to the resident - illustrates the gap between knowledge and implementation.
Nursing homes typically establish multiple checkpoints to prevent call bell violations. Staff are generally required to ensure call bell placement during routine rounds, shift changes, and after providing care. The failure at Woodmont Center suggests breakdown in these systematic safeguards.
The inspection occurred on a Sunday afternoon, when nursing facilities often operate with reduced staffing levels. Weekend shifts can strain normal safety protocols, but federal regulations make no allowances for staffing variations in basic safety requirements.
Woodmont Center's administrator and interim director of nursing were notified of the violation on August 26 at 4:08 p.m. The inspection report notes that facility leadership was "made aware of the above concern" but provides no details about their response or corrective actions.
The timing of the notification - nearly 24 hours after inspectors documented the violation - raises questions about the facility's immediate response to safety concerns. Federal protocols typically require nursing homes to address immediate jeopardy situations within hours, though this violation was classified at a lower harm level.
Call bell violations can escalate quickly in nursing home environments. Residents who cannot summon help may experience prolonged distress, delayed medical attention, or injuries from attempting to reach assistance independently.
The inspection was conducted as part of a complaint investigation, meaning someone had contacted federal or state authorities with concerns about care at Woodmont Center. The report does not specify whether call bell access was the subject of the original complaint or discovered during the broader investigation.
Federal inspectors examined ten residents during their survey sample. Finding call bell violations affecting one of ten residents suggests the problem may be more widespread than documented in this single case.
Woodmont Center must now submit a plan of correction to federal regulators detailing how they will prevent future call bell violations. The facility faces potential financial penalties if inspectors find similar violations during follow-up visits.
The resident who spoke with inspectors remains at Woodmont Center, dependent on staff to remember basic safety protocols that could mean the difference between timely help and dangerous isolation when emergencies arise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodmont Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WOODMONT CENTER in FREDERICKSBURG, VA was cited for violations during a health inspection on August 27, 2025.
The resident, identified in the inspection report as Resident #6, told inspectors that staff do respond when she uses her call bell.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.