When inspectors tested the call bell system on October 20, they found that Resident #18's call bell would turn on the alert light outside her room but wouldn't turn off when staff pressed the wall button to acknowledge her call. The resident told inspectors she had "repeatedly requested repair of this issue, which had not been addressed."
The malfunction meant staff couldn't properly reset the system after responding to calls, potentially creating confusion about whether the resident still needed help.
Geriatric Nursing Assistant #8, who witnessed the test with inspectors, said she would need to contact maintenance to manually turn off the light and report the problem. But when inspectors checked with the Maintenance Director later that day, no work order had been entered into the facility's computer system for Resident #18's room until 11:54 AM that morning — nine minutes after inspectors discovered the problem.
The inspection revealed a broader pattern of call bell failures throughout the facility. When inspectors tested Resident #20's call bell, it didn't work at all. The button failed to trigger any alert light when pressed, leaving the resident with no way to summon help in an emergency.
Again, no work order existed in the facility's tracking system for that room's call bell.
The Maintenance Director told inspectors he would repair both call bells after their interview. By 3:10 PM that same day, he reported the repairs were complete. The next morning, Resident #18 confirmed her call bell light had been fixed, and inspectors observed that Resident #20's call bell had been replaced entirely.
But the facility's own audit revealed the scope of the problem extended far beyond the two rooms inspectors initially tested.
After being confronted by federal inspectors, the Administrator announced that a comprehensive call bell audit would begin immediately to check every resident room. The Maintenance Director started the facility-wide inspection that same day.
His findings were striking. The audit identified call bell failures in the rooms of Residents #19, #20, #22, #23, #24, and #25. Combined with Resident #18's malfunctioning system, seven of the seven residents whose call bells inspectors reviewed had problems with their emergency communication devices.
The Maintenance Director's documentation showed he repaired all six additional call bells on October 21, the day after inspectors arrived.
Call bell systems serve as residents' primary lifeline to nursing staff, especially during emergencies or when residents need assistance with basic care. The devices are designed to activate both visual and audible alerts that notify staff when residents press their call buttons. When staff respond and press the wall button to acknowledge the call, the signal should turn off automatically.
Federal regulations require nursing homes to maintain functioning call systems in all resident areas, including bathrooms and bathing areas, to ensure residents can reliably summon help.
The timing of the facility's response raised questions about its maintenance practices. Despite Resident #18's repeated requests for repairs, the facility only entered a work order after federal inspectors discovered the problem. The comprehensive audit that revealed six additional broken call bells began only after the Administrator was informed of the inspection findings.
The facility's computerized Total Equipment Logging System, known as TELLS, showed no previous work orders for most of the malfunctioning call bells, suggesting the problems had gone unaddressed despite their critical importance for resident safety.
Resident #20 was asleep when inspectors returned to check the replacement call bell, but they confirmed the new device was within reach. The resident had spent an unknown period without any functioning way to alert staff to emergencies or care needs.
The inspection occurred in response to a complaint, though the report doesn't specify what prompted the federal review. Inspectors classified the violation as causing "minimal harm or potential for actual harm" to residents.
All seven residents whose call bells were reviewed during the survey had experienced problems with their emergency communication systems. The facility completed repairs only after federal oversight forced a systematic review of equipment that residents depend on for their safety and basic care needs.
The rapid completion of repairs once inspectors arrived demonstrated the facility had the capability to maintain functioning call bell systems. The question remained why seven residents had to wait for federal intervention to get working emergency communication devices.
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.
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