Federal inspectors found Resident C lying in bed with eyes closed on January 28, completely unable to summon assistance. The patient suffered from anoxic brain injury, where the brain was completely deprived of oxygen and cells died, along with acute respiratory failure and dangerous carbon dioxide buildup in the bloodstream.
The facility's own care plan from January 13 specifically noted the resident was at high risk for falls and required the call light to be placed within reach at all times.
Instead, inspectors observed only a single call cord in the room. That cord served the resident's roommate.
Resident C had no call system whatsoever.
Certified Nursing Assistant 5 entered the room during the inspection and confirmed she could not locate any call light for Resident C. She acknowledged there should have been a split call cord allowing both residents to summon help.
Licensed Practical Nurse 6 told inspectors that all residents should have call lights within reach.
The facility's own written policy, provided the next day by the Regional Nurse Consultant, required "a functioning call light in an accessible location to where the resident is located in their room." The policy emphasized staff must "respond promptly to a residents' call for assistance."
For a patient whose brain had been starved of oxygen and whose lungs struggled to function properly, the absence of any emergency communication represented a fundamental safety failure. The resident remained completely dependent on staff happening to check the room.
The violation affected multiple residents and connected to three separate complaint investigations at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Scottsburg, The from 2026-01-29 including all violations, facility responses, and corrective action plans.