Resident C suffered anoxic brain injury, a condition where the brain was completely deprived of oxygen, causing cells to die. He also battled 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 care plan from January 13 specifically noted he was at risk for falls and required his call light within reach.
But when a federal inspector visited on January 28 at 1:26 p.m., Resident C was resting in bed with his eyes closed and no call light in place. 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 saw no call light for Resident C. She told the inspector 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 to inspectors the following day, states it is facility policy "to have a system in place to allow staff to respond promptly to a residents' call for assistance" and that "the call system will be available in the resident's room."
The policy's procedures require staff to "always be sure that the resident has a functioning call light in an accessible location."
The violation occurred during a complaint investigation at The Waters of Scottsburg, affecting what inspectors classified as "few" residents with minimal harm or potential for actual harm.
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.