Shelby Health And Rehabilitation Center

reported staff really can't tell who it is that is ringing the bell and what happens if the need is more urgent.

On 09/04/24 at 12:38 PM, Licensed Practical Nurse (LPN) D reported the call light system was an electrical issue and most every unit was affected. LPN D reported each new admission is given a hand bell. LPN D further commented it was hard to distinguish where ring was coming from, and they may not hear it if not in the immediate area. At 12:45 PM, CNA E reported call light system problems going back four months and reported it was difficult when more than one resident was ringing their handbell at the same time. CNA E noted one would have to go to the rooms of the residents and ask if they had rung their bell. At 1:19 PM, CNA H reported they had worked on the 300 unit and was told the unit call system was not working and the residents had been given hand bells, but had not had any specific training or program change related to resident assistance or monitoring, At 1:45 PM, the Assistant Maintenance Director (AMD) reported the call system had been down for three and a half weeks after a repair blew out two other boards. It was completely down on five units at the facility.

The AMD did not have a date for the completion of the repair.

On 09/04/25 at 2:16 PM, the Director of Nursing (DON) was asked about the call system outage and reported new admits are given hand bell and staff are expected to round on the residents.

The DON confirmed unit one, three, five, seven and nine had the call light outage.

The DON was asked about discussion of an action plan in the Quality Assurance (QA) meetings and reported they were not sure if there was a formal education plan written, but it was discussed.A request for an action plan for call lights from QA was requested to be provided if available on 09/04/25 at 3:23 PM via email and not received prior to survey exit.A review of the QA committee agenda received 09/04/25 at 2:33 PM via email revealed no specific reference to the call light outage.

The Administrator documented, Our Monthly QA Agenda/Template remains the same for every month.A review of a facility invoice dated 07/11/25 noted parts had been ordered for the call system.

Ongoing expenses for the call system were documented on 08/06/25, 08/11/25 and 08/15/25.

The August expense report noted there were three units down.

Additional document review for communications with the repair company noted an outage from 06/26/25 for the entire 900 unit.On 09/04/25 at 3:05 PM, the Inservice Director provided education from a March 2025 plan of correction for call lights out of reach and an example of notes from a unit staff five-minute huddle/meeting dated June 11, 2025, for units 300, 500 and 700 that documented call lights are to be responded to in a timely manner. A review of the facility policy titled, Care Plan - Comprehensive and Revision dated 08/08/22, documented, A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A review of the policy titled, Accommodation of Needs dated 08/21/23, documented, The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodation for the individual needs and preferences of a resident .A review of the facility policy titled, Call Light Accessibility and Timely Response dated 08/16/23 documented, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet and bathing facility to allow residents to call for assistance.

Call light will directly relay to a staff member or centralized location to ensure appropriate response.

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