Salem Health & Rehab: Call Bell Safety Failures - VA
Federal inspectors documented the safety failure during a complaint investigation in late August, finding the call bell consistently out of reach for Resident #5 despite the person's documented physical limitations and cognitive impairment.
The resident's medical record showed diagnoses including idiopathic peripheral autonomic neuropathy, type 2 diabetes, and muscle weakness. A June assessment scored the resident 12 out of 15 on a cognitive evaluation, indicating moderate impairment that affects their ability to think clearly and make decisions.
On August 26 at 2:30 p.m., inspectors found the resident resting in bed with eyes closed while the call bell lay on the floor beside the bed. The next morning at 9:45 a.m., inspectors returned to find the resident sitting up in bed with the call bell still on the floor.
That afternoon at 1:20 p.m., the situation had worsened. The resident sat in a wheelchair beside the bed, but the call bell now lay on the opposite side of the bed, completely out of reach.
When an inspector asked if the resident could reach the call bell, the person replied, "I guess I could get to it if I really had to."
The following morning on August 28 at 8:35 a.m., inspectors found the resident sitting up in bed with the call bell once again on the floor beside the bed.
The director of nursing acknowledged the violation when questioned by inspectors that afternoon. She confirmed that call bells should remain within reach whether residents are in bed or sitting in chairs.
The facility's own training materials supported this requirement. Inspectors obtained a copy of Mosby's Textbook for Long-Term Care Assistants used by the facility, which states: "Always keep the call light within the person's reach — in the room, bathroom, and shower or tub room."
Call bells serve as residents' primary lifeline to help during medical emergencies, falls, or other urgent situations. For residents with physical limitations like muscle weakness, reaching a call bell that has fallen becomes nearly impossible without assistance.
The cognitive impairment documented in Resident #5's case compounds the safety risk. Moderately cognitively impaired residents may not fully understand the danger of being unable to summon help or may forget to ask staff to reposition their call bell.
Federal regulations require nursing homes to reasonably accommodate each resident's needs and preferences. Keeping emergency communication devices accessible represents a basic accommodation for residents with physical and cognitive limitations.
During the three-day observation period, multiple staff members would have entered the resident's room for routine care, meals, and medication administration. Each missed the obvious safety hazard of the call bell lying on the floor or positioned out of reach.
The violation affects what inspectors classified as "few" residents, suggesting similar call bell accessibility problems may exist for other residents at the facility. The inspection occurred following a complaint, indicating someone reported concerns about care quality at Salem Health & Rehabilitation.
Inspectors presented their findings to facility leadership on August 28 at 4:00 p.m., meeting with the administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services.
The facility provided no additional information before inspectors completed their investigation.
Resident #5's situation illustrates how seemingly minor oversights can create serious safety risks for vulnerable nursing home residents. A call bell on the floor means no way to summon help during a fall, choking incident, cardiac event, or other emergency requiring immediate assistance.
For residents with muscle weakness and cognitive impairment, the inability to reach emergency help transforms routine care into a potentially dangerous situation where medical crises could go unnoticed for hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salem Health & Rehabilitation from 2025-08-28 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 19, 2026 · Our methodology
SALEM HEALTH & REHABILITATION in SALEM, VA was cited for violations during a health inspection on August 28, 2025.
The resident's medical record showed diagnoses including idiopathic peripheral autonomic neuropathy, type 2 diabetes, and muscle weakness.
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.