Doctors Nursing & Rehab: Call Light Failures - IL
The residents — two with severe cognitive impairment and one with respiratory failure — shared a room where none of their call lights functioned. When industrial fans ran to combat air conditioning problems, staff couldn't hear the hand bells over the noise.
"When the facility has the industrial fans running, I have to ring my hand bell for long periods of time because I assumed staff could not hear her bell over the fans," one cognitively intact resident told inspectors on August 6.
The maintenance director knew about the broken call lights but said the repair company "would not come to the facility due to the facility not paying their bill." The former administrator claimed he was unaware of the unpaid bills and said he would contact corporate for direction.
One resident's call light had been broken for approximately two months. Another resident's light stopped working about a week before the investigation. The third resident, who suffered from hemiplegia following a stroke and severe cognitive impairment, relied entirely on roommates and hand bells for assistance.
Staff confirmed the residents' accounts about the industrial fans drowning out their emergency signals.
"When the industrial fans were running, they were so loud staff could barely hear the phone ringing and if staff were down the hall away from the room, staff would not be able to hear their hand bells ringing," a licensed practical nurse told inspectors.
A certified nursing assistant was more direct: "When the industrial fans were running, there was no way staff could hear the hand bells if staff were down the hall or at the nurse's station."
The facility's own policy required staff to "report all defective call lights to the nursing supervisor promptly." But when the current administrator asked corporate for guidance about what to do when call lights weren't working, she was told "they could not find one."
A family member who visited every Sunday discovered her relative had been given a hand bell on July 27. When she asked staff why, they explained the call light wasn't working. She witnessed the industrial fans running and confirmed staff couldn't hear the hand bell ringing over the noise.
The broken call lights affected residents with varying levels of cognitive function and medical needs. One resident had been admitted in February 2018 with hemiplegia following a stroke, vascular dementia, and need for assistance with personal care. Her cognitive assessment score of 5 indicated severe impairment.
Another resident, admitted in August 2024, had chronic respiratory failure and a history of stroke. Her cognitive score of 9 showed moderate impairment.
The third resident, admitted in December 2023, suffered from motor neuron disease, respiratory failure, and chronic pain but remained cognitively intact with a score of 15.
Before her own call light broke, the cognitively intact resident had been helping her roommates by using her functioning light when they needed assistance. Once all three lights failed, the hand bell system became their only option for summoning help.
Federal inspectors tested all three call lights during their visit and confirmed none were working.
The facility's air conditioning problems, which necessitated the loud industrial fans, created an additional layer of danger. The fans ran at both ends of the hallway where the residents lived, making it nearly impossible for staff to hear emergency calls from the room.
The administrator's request to corporate headquarters on August 8 for a policy about non-functioning call lights revealed the facility lacked basic procedures for handling equipment failures that could endanger resident safety.
When inspectors returned on August 12, the administrator confirmed corporate could not locate any policy addressing what to do when call lights stopped working, despite the facility's written requirement to report defective equipment promptly.
The three residents continued using hand bells as their primary means of requesting assistance, hoping staff would hear them over the industrial fans that had been running for weeks to address the facility's ongoing air conditioning problems.
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.
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
DOCTORS NURSING & REHAB CENTER in SALEM, IL was cited for violations during a health inspection on August 12, 2025.
The residents — two with severe cognitive impairment and one with respiratory failure — shared a room where none of their call lights functioned.
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.