The October 24 complaint inspection found every resident reviewed for call bell access — four out of four — unable to summon help when needed. One call bell was locked inside a bedside table drawer. Another was wrapped tightly around a bed rail on the opposite side of the room from where the resident sat in a wheelchair.
Call bells serve as lifelines for nursing home residents, allowing them to request assistance for medical emergencies, bathroom needs, or falls. Federal regulators define them as communication devices that "allow residents to summon staff assistance when needed."
At 11:11 AM on October 20, an inspector found Resident #15 lying in bed with the call bell stored inside the bedside table drawer, completely out of reach. Ten minutes later, Resident #16 sat in a wheelchair eating breakfast while their call bell remained on the opposite side of the bed.
Resident #17 faced a similar problem at 11:24 AM. The call bell was wound tightly around the bed rail on the far side of the bed while the resident sat in a wheelchair on the opposite side of the room.
When confronted with the violations, Registered Nurse #6 acknowledged her responsibility. She told the inspector that ensuring residents have access to call lights fell to both nurses and aides. During a joint observation in two residents' rooms where call bells were unreachable, the nurse "acknowledged the issue, apologized, and repositioned the call lights so they were accessible to the residents."
The most troubling discovery came in Resident #20's room at 11:52 AM. The call bell lay on the floor underneath the roommate's bed, requiring the inspector to retrieve it.
Geriatric Nursing Assistant #8, when questioned about her process for ensuring call bell access, provided a vague response. She stated "that she typically checks to make sure residents have their call bells but did not specify a consistent schedule for doing so."
During a demonstration with GNA #8 in Resident #20's room, the aide retrieved the call bell from the floor and handed it to the resident. The inspector explained that residents must have access to their call bells to contact healthcare staff. The aide said she understood the concern.
The systematic nature of the problem became clear through the inspection timeline. Within a 41-minute window on October 20, inspectors documented four separate call bell violations across different rooms and different staff members.
The facility's response came the following day. On October 21 at 11:17 AM, the Administrator was briefed on the findings and the interviews with nursing staff. The Administrator promised that "a call bell audit would begin that day to check every call bell in each resident room and address the issue."
The violations represent a fundamental breakdown in basic safety protocols. Federal regulations require nursing homes to "reasonably accommodate the needs and preferences of each resident." Access to emergency communication represents one of the most basic accommodations a facility must provide.
The inspection classified the violations as causing "minimal harm or potential for actual harm," but the implications extend beyond the regulatory language. Residents unable to summon help face increased risks during medical emergencies, falls, or other urgent situations requiring immediate staff response.
For facilities accepting Medicare and Medicaid funding, call bell accessibility represents a non-negotiable safety requirement. The devices must remain within reach regardless of whether residents are in bed, seated in wheelchairs, or moving around their rooms.
The October inspection was conducted in response to a complaint, suggesting someone had previously raised concerns about resident access to emergency communication. The facility houses residents who depend on staff assistance for various daily needs, making reliable communication systems essential for their safety and wellbeing.
Complete Care at Severna Park's Administrator committed to conducting facility-wide call bell audits, but the inspection revealed a pattern of staff either forgetting or failing to prioritize this basic safety check. Four different residents in four different rooms all faced the same problem on the same morning.
The nursing assistant's inability to specify a consistent schedule for call bell checks suggests the facility lacked systematic protocols for ensuring emergency communication access. Without clear procedures and regular monitoring, residents remain vulnerable to periods when they cannot request help.
The inspection findings will be made public 14 days after the facility receives the report, as required for nursing homes receiving federal funding. The facility must submit an approved plan of correction to maintain program participation in Medicare and Medicaid.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Severna Park LLC from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Complete Care At Severna Park LLC
- Browse all MD nursing home inspections