Federal inspectors discovered the safety violation during a complaint investigation in October. When they asked the resident if they knew where their call bell was, the person shook their head no.
The sequence began on October 16 at 12:15 PM, when an inspector entered the resident's room and found the call bell plunger lying on the floor beside the bed. The handheld device, which residents use to alert staff when they need assistance, had fallen to the right side of the bed and remained there.
The inspector immediately left the room and notified a nurse about the situation. Staff member #20 came to the room, put on gloves, and picked up the call bell from the floor. She placed it on the bed.
But the fix didn't last.
The next morning at 9:10 AM, the same inspector returned to check on the resident. The call bell plunger was now hanging down from the bed near the top of the right-side transition rail, still beyond the resident's reach.
When the inspector asked the resident directly if they knew where their call bell was located, the person indicated they did not.
The call bell system represents a critical safety feature in nursing homes, designed to ensure residents can summon help during medical emergencies, falls, or other urgent situations. When residents cannot access their call buttons, they may be left unable to request assistance for hours.
This resident's experience illustrates how quickly safety measures can break down. Even after staff corrected the problem once, the call bell became inaccessible again within less than 21 hours.
The Director of Nursing was interviewed about the violations on October 17 at 10:35 AM. When inspectors informed her of what they had observed over the two-day period, she responded that she would talk to the nursing staff and address the issue with them.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to residents. The deficiency fell under regulations requiring facilities to "reasonably accommodate the needs and preferences of each resident."
The inspection was conducted as part of a complaint survey, meaning federal or state officials received a specific allegation about conditions at the facility that triggered the investigation. Inspectors examined eight residents as part of their survey sample and found the call bell problem affected one of them.
Autumn Lake Healthcare at Patuxent River is located on Laurel Park Drive in Laurel, Maryland. The facility must submit a plan of correction to federal regulators detailing how it will prevent similar violations in the future.
The inspection report notes that "few" residents were affected by the deficiency, but does not specify whether other residents experienced similar problems with their call bell access during the survey period.
For residents who cannot easily move or reposition themselves in bed, an inaccessible call button can create dangerous situations. If they experience a medical emergency, fall, or need assistance with basic care, they may have no way to alert staff members.
The nursing staff's response to the first incident suggests they understood the seriousness of the problem. The nurse put on gloves before handling the call bell, indicating awareness of infection control protocols, and immediately placed the device back on the bed where the resident could theoretically reach it.
However, the call bell's position the following morning indicates that either the placement was inadequate or the device moved again due to the resident's movements or other factors.
The resident's inability to locate their call bell when asked directly by inspectors underscores the practical impact of the violation. Even when the device was technically in the room, it remained functionally useless to the person who needed it.
The Director of Nursing's promise to address the issue with staff suggests the facility recognized the problem as a training or procedural matter rather than an equipment failure.
This violation occurred during what inspectors classified as a complaint survey, meaning someone filed a specific concern about conditions at the facility that prompted the federal investigation in October 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Patuxent River from 2025-10-17 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Autumn Lake Healthcare At Patuxent River
- Browse all MD nursing home inspections