Resident C suffered anoxic brain injury, meaning his brain was completely deprived of oxygen, causing cells to die. He also had acute respiratory failure with hypoxia and hypercapnia — life-threatening conditions where the lungs fail to oxygenate blood and carbon dioxide builds up in the bloodstream.
His January 13 care plan at Waters of Scottsburg identified him as at risk for falls and directed staff to place his call light within reach.
But when inspectors observed his room on January 28 at 1:26 p.m., Resident C was resting in bed with his eyes closed and no call light available. Only one call cord existed in the room, positioned for his roommate's use.
Certified Nursing Assistant 5 entered the room one minute later and confirmed she didn't see a call light for Resident C. She told inspectors there should have been a split call cord in the room to serve both residents.
Licensed Practical Nurse 6 acknowledged that all residents should have a call light within reach.
The facility's own policy, provided by the Regional Nurse Consultant, states that a call system must be available in each resident's room and that staff should "always be sure that the resident has a functioning call light in an accessible location."
For Resident C, whose brain injury and respiratory complications made him particularly vulnerable, the missing call system meant no way to alert staff if he needed immediate assistance. His documented fall risk made the violation particularly concerning, as he had no means to summon help if he attempted to get out of bed without assistance.
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.