Waters of Scottsburg: Elopement Monitoring Failure - IN
The resident, identified in inspection records as Resident B, had suffered a cerebral infarction, the kind of brain damage that kills tissue and, in his case, left him unable to reliably communicate. He couldn't always say what he needed. What he could do, repeatedly and consistently, was make clear he wanted out. He gestured toward exits. He told staff he was going to leave. He said he didn't want to be there.
The facility's own care plan, dated April 24, acknowledged all of it. The interdisciplinary team had flagged him as an elopement risk tied to periods of confusion and his inability to express his needs verbally. The plan was in the chart. The risk was documented. The monitoring never started.
What happened in the weeks before inspectors arrived tells the story of what that gap cost.
On April 19, Resident B left the facility on a leave of absence with a family friend and did not come back until the following day. When he did return, he refused to get out of the vehicle. Staff called EMS. He was taken to a hospital for evaluation and brought back to Waters of Scottsburg the day after that.
None of that resolved his desire to leave. The interdisciplinary team noted on April 27 that he had continued to express his wish to go and kept showing exit-seeking behaviors after returning from the hospital. The pattern, the team wrote, was consistent.
Eight days after that leave of absence, on April 25, at approximately 8:06 in the evening, Resident B was found off facility grounds. He was located on the roadside.
The inspection report does not describe what condition he was in when found, or how long he had been outside, or what the weather was. It records the time, the location, and the fact that it happened. That is enough.
A staff member identified in the report as Staff Member 17 told inspectors that Resident B had been showing exit-seeking behaviors before the day he eloped. Not after, not as a surprise. Before. The signs were there and the people working with him knew it.
When inspectors interviewed the facility's social services staff on April 30, the response was direct: Resident B should have had behavior monitoring in place for his exit-seeking behaviors. The Regional Director of Operations handed over a copy of the facility's own Behavior Management Program, dated May 2024. It stated that every resident identified as exhibiting problematic behavior would be observed to identify contributing factors and find appropriate interventions. It stated that each such resident would have a form for monitoring their status. It stated that a behavior management logbook would list behaviors and interventions specific to the resident.
There was no such form for Resident B. There was no logbook entry. The clinical record had no documentation that behavior tracking had ever been implemented, despite the care plan, despite the team notes, despite the elopement, despite the hospital visit, despite everything that had already happened.
The inspection was triggered by a complaint and completed April 30. Inspectors classified the violation as carrying minimal harm or potential for actual harm, a finding that reflects the regulatory floor, not necessarily what it means to be a cognitively impaired man who cannot fully communicate his needs, found by the side of a road after dark.
His care plan said he was at risk. His team said the pattern was consistent. His facility had a written policy that required someone to start a monitoring form. Nobody had.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Scottsburg, The from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
WATERS OF SCOTTSBURG, THE in SCOTTSBURG, IN was cited for violations during a health inspection on April 30, 2026.
He couldn't always say what he needed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.