Resident C told federal inspectors on September 22 that when he moved into his room at Envive of Lawrenceburg, maintenance staff informed him there was no spot to hook up a call light. He had been in the room for "a few months" and never received one.
The facility gave him a bell to ring instead. But he lost it.
Even when he had the bell, staff couldn't hear it because his room was "at the last room at the end of the hallway," he told inspectors. When he needed help, he would wheel himself to the bathroom and use the call light there.
But that night when he couldn't get out of bed, he had no choice but to yell.
The resident, who uses a wheelchair due to stroke-related impairment on one side of his body, is cognitively intact according to his June assessment. His medical record shows he requires moderate assistance with lower body dressing.
When Registered Nurse 2 accompanied inspectors to the resident's room that morning, she confirmed there was no call light plugged into the wall above his bed. She pointed to where it should have been and asked the resident directly if he had ever had a call light.
"Resident C replied he had not ever had a call light."
The nurse told inspectors the wheelchair-using resident "should have had a call light at the bedside at all times."
The Maintenance Supervisor knew about the problem. He explained to inspectors that the room was originally a single room, so a second call light was never installed when it became occupied.
Emails provided by the Administrator revealed the facility had been trying to order call light boxes since at least July 22. On that date, staff emailed asking if the boxes were on backorder because they hadn't received them yet.
No follow-up emails were sent for two months.
On September 22 — the same day inspectors arrived — staff finally sent another email asking about the order. The supplier replied that afternoon that the boxes were being shipped that day.
The Administrator told inspectors that by 1:50 that afternoon, Resident C had a functioning call light. They had hooked up "the old call light for the room."
But when inspectors tested it at 3:30 that afternoon, problems persisted.
Resident C pressed his call light button while lying in bed. The light above his room door didn't illuminate. There was no sound.
He then hit the bell — now placed back on his bedside table — three times and dropped it onto the floor.
Nobody came.
The Administrator explained that the resident's call light was working, but the indicator light was located "overtop of the stairwell beside his room" rather than above his door. She also acknowledged there was no sound at the nurses station when this resident pressed his call light, unlike the other call lights in the facility.
The facility's own policy, revised in August 2024, requires staff to "be sure that the call light is plugged in and functioning at all time" and "ensure that the call light is accessible to the resident when in bed." Staff are supposed to "report all defective call lights to the nurse supervisor promptly."
Federal inspectors found the facility violated requirements to provide adequate communication systems that relay calls directly to staff from residents' bedsides.
For months, a cognitively intact resident who couldn't always get out of bed was left to yell for help in medical emergencies. The facility knew about the missing call light but took no action for at least two months between follow-up orders.
Even after promising the problem was fixed, the hastily installed replacement system remained partially broken, with no audible alert and an indicator light located away from the resident's room where staff might not notice it.
The resident who had to yell for help while vomiting still had no reliable way to summon assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Envive of Lawrenceburg from 2025-09-22 including all violations, facility responses, and corrective action plans.