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, a life-threatening condition where the lungs fail to oxygenate the blood, and hypercapnia, the buildup of too much carbon dioxide in the bloodstream.
His care plan from January 13 specifically noted he was at risk for falls and required his call light to be placed within reach.
But when inspectors observed his room on January 28 at 1:26 p.m., the resident was resting in bed with his eyes closed and had no call light available. The room's single call cord was positioned for his roommate's use only.
Certified Nursing Assistant 5 entered the room one minute later and confirmed she could not see a call light for Resident C. She said there should have been a split call cord in the room to serve both residents.
Licensed Practical Nurse 6 told inspectors that all residents should have a call light within reach.
The facility's own policy, provided by the Regional Nurse Consultant, states that staff must "always be sure that the resident has a functioning call light in an accessible location to where the resident is located in their room."
The violation affected few residents, according to the inspection report. Federal regulators classified the harm level as minimal or potential for actual harm.
The citation stemmed from three separate complaint intakes filed against 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.