Shelby Health and Rehab: Call System Down 4 Months - MI
The facility's electronic call light system had been failing for months. By the time a state inspector arrived on September 4, 2025, five of the facility's units — one, three, five, seven, and nine — had no working call lights at all. In their place, staff handed new admissions a small hand bell and told them to ring if they needed something.
The problem with that, as a certified nursing assistant explained to the inspector, was that when more than one resident rang at the same time, staff couldn't tell where the sound was coming from. They had to walk from room to room, knocking, asking whether each person had been the one ringing.
CNA E told the inspector the call light problems stretched back four months. Another nursing assistant, CNA H, said they'd been told the unit call system wasn't working and residents had been given hand bells, but that there had been no specific training or program change related to how staff should monitor or respond to residents differently as a result.
Licensed Practical Nurse D put it plainly: it was hard to distinguish where a ring was coming from, and staff might not hear it at all if they weren't in the immediate area.
That's not a minor inconvenience in a nursing home. Residents ring call lights because they're falling, because they need medication, because they're in pain and can't get out of bed on their own. A hand bell that nobody hears is not a substitute.
The Assistant Maintenance Director told the inspector the system had been completely down for three and a half weeks on those five units after a repair attempt blew out two additional circuit boards. But invoices the inspector reviewed told a longer story. Parts had been ordered as far back as July 11. Expenses for ongoing repair work were documented on August 6, August 11, and August 15. A separate document showed one unit, the 900 unit, had been experiencing an outage since June 26. When the inspector asked the Assistant Maintenance Director when the repairs would be finished, he didn't have a date.
The Director of Nursing confirmed the five-unit outage and said staff were expected to round on residents more frequently as a workaround. When asked whether the facility's Quality Assurance committee had developed a formal action plan to address the situation, the Director of Nursing said they weren't sure whether anything had been written down, but that it had been discussed.
It had not been written down. A review of the QA committee agenda showed no specific reference to the call light outage. The administrator explained that the monthly QA agenda template was the same every month. An inspector requested any available action plan by email at 3:23 PM. Nothing arrived before the inspection ended.
What the facility did produce was a March 2025 plan of correction related to call lights being out of reach, and notes from a staff huddle held on June 11, 2025, reminding workers on units 300, 500, and 700 that call lights should be responded to in a timely manner. That huddle happened to be about a different problem, in a different month, on different units. It was the closest thing to documentation the facility had.
The facility's own call light policy, dated August 2023, states that the purpose of the system is to assure residents can call for assistance from their bedside, toilet, and bathing area, and that calls will relay directly to a staff member or centralized location. The policy was on paper. The system was not working.
The violation was cited at a level of minimal harm or potential for actual harm. That classification reflects what inspectors documented, not what could have happened on any given night when a resident on unit three or unit seven rang a small brass bell into a hallway and waited.
The repair company had been in contact with the facility since at least late June. As of September 4, nobody could say when the lights would come back on.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shelby Health and Rehabilitation Center from 2025-09-04 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: August 5, 2026 · Our methodology
Shelby Health and Rehabilitation Center in Shelby Township, MI was cited for violations during a health inspection on September 4, 2025.
The facility's electronic call light system had been failing for months.
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.