Shelby Health And Rehabilitation Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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Shelby Health and Rehabilitation Center in Shelby Township, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Shelby Township, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Shelby Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.