Doctors Nursing & Rehab: Call Light Failures - IL
The situation at Doctors Nursing & Rehab Center came to light during a complaint inspection conducted July 30, 2025. Inspectors found that residents in a shared room — identified in records as R2, R3, and R4 — had hand bells sitting on their bedside tables because the call light system in their room had stopped working. When inspectors tested the call lights, none of them functioned.
R4, who is cognitively intact and had been admitted in December 2023 with motor neuron disease, respiratory failure, and chronic pain, told inspectors the call light had stopped working about a week before they arrived. She said that until her own light failed, she had been using it to call for help on behalf of R3 as well.
R3, admitted in August 2024 with chronic respiratory failure and a history of cerebral infarction, told inspectors her call light had not been working for a couple of months. She said she had been told the facility was waiting on parts.
R2, admitted in February 2018 following a cerebral infarction and living with vascular dementia and hemiplegia, had a cognitive assessment score indicating severe impairment. R2's family member, who holds power of attorney and visits every Sunday, said she noticed the hand bell on R2's bedside table on July 27 and asked staff why it was there. She was told the call light wasn't working. She said she understood that when the industrial fans were running, staff could not hear R2's bell ring.
The fans were not a minor inconvenience. The facility had been dealing with air conditioning problems and had placed large industrial fans at both ends of the hall where all three residents lived. A licensed practical nurse told inspectors the fans were so loud that staff could barely hear the phone ringing at the nurses' station, and that if staff were down the hall away from the room, they would not be able to hear the hand bells at all. A certified nursing assistant said the same thing: when the fans were running, there was no way to hear the bells from down the hall or from the nurses' station.
R4 told inspectors on August 6 that she had to ring her hand bell for long periods of time when the fans were on because she assumed staff could not hear her.
The reason the call lights had not been repaired turned out to be straightforward, and troubling. The maintenance director told inspectors the facility's call light repair company had informed him they would not come to the facility because the facility had not paid its bill. The former administrator, interviewed the same day, said he was unaware the repair company had stopped coming for that reason and would contact corporate for direction.
By August 12, when a new administrator had taken over, she told inspectors she had asked corporate on August 8 for a policy on what to do when call lights are not functioning. She said corporate told her they could not find one. The facility's own written policy, dated July 2014, stated that defective call lights should be reported to the nursing supervisor promptly. It said nothing about what should happen if they stayed broken.
The gap between what that policy promised and what these three residents experienced, measured in weeks and months, was filled by small brass bells and the hope that someone nearby could hear them over the roar of industrial fans. For R2, who cannot reliably communicate her needs and has lived at the facility since 2018, there was no way to know how long she had been ringing and no way to know if anyone heard.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Doctors Nursing & Rehab Center from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
DOCTORS NURSING & REHAB CENTER in SALEM, IL was cited for violations during a health inspection on August 12, 2025.
The situation at Doctors Nursing & Rehab Center came to light during a complaint inspection conducted July 30, 2025.
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.