Stonebrooke Rehab: Abuse Reporting Failure - IN
The incident at Stonebrooke Rehabilitation Center, which occurred on October 15, 2025, is the subject of a complaint inspection completed October 23 by Indiana state surveyors. The inspection cited the facility for failing to timely report an alleged incident of verbal abuse to the executive director, affecting one resident identified in the report as Resident C.
Resident C is cognitively intact. Her diagnoses include chronic pain syndrome, major depressive disorder, and hypertension. She was, according to the inspection record, upset and tearful after the encounter.
The nursing assistant at the center of the incident is identified only as CNA 9. What she did that morning was witnessed, or later described to staff, by at least three people before the executive director was told anything at all.
The first to know was a colleague. A second certified nursing assistant, identified as CNA 2, told inspectors she witnessed the incident firsthand. CNA 9 had rushed in and out of Resident C's room, hushed her during care, made hand gestures for her to stop talking when the resident was apologizing for being wet, threw dirty linens on the floor, and made the remark about being covered in urine, all in front of Resident C.
CNA 2 said she should have notified the executive director sooner. Instead, she wrote out a statement describing what she had seen and slid it under the doors of the facility's directors that night, meaning the directors received it the morning of October 16. That was her chosen method of reporting a witnessed abuse allegation: a paper statement, slipped under doors, overnight.
The occupational therapist who worked with Resident C that same afternoon had a different path to the same information. During a therapy session in Resident C's room on October 15, the resident was tearful and told the therapist that CNA 9 had rushed in and out of her room earlier that day, hushed her during care, and made hand gestures for her to stop talking when she was apologizing for being wet. The occupational therapist went to the social services director with what she had heard. The social services director was in a family meeting. She told the occupational therapist she would notify the executive director once she was done.
The social services director, interviewed by inspectors on October 23, said the occupational therapist had told her only that Resident C had been crying and needed someone to check on her. She said she visited Resident C on October 15 but that the resident did not tell her what had happened with CNA 9 that morning. The resident did not describe the incident to the social services director until October 16.
That is the timeline as it was reconstructed for inspectors: a cognitively intact woman with major depressive disorder, already tearful after being told to shut up during the most intimate kind of care, had at least two staff members aware something had happened to her by the afternoon of October 15. Neither of them reached the executive director that day.
The director of nursing told inspectors she had no knowledge of the incident until she arrived at work the morning of October 16 and found CNA 2's written statement on the floor under her door. She read it, then called the executive director, who was off that day.
The executive director told inspectors she did not know the situation involved an alleged abuse allegation until she began investigating and spoke with Resident C herself. She then reported the incident to the Indiana Department of Health.
The facility's own abuse policy, provided to inspectors by the executive director, states plainly that any individual who witnesses abuse or has suspicion of abuse shall immediately notify the charge nurse and the executive director. CNA 2 witnessed the incident. She wrote a statement. She put it under doors. She did not call anyone. The occupational therapist heard the resident's account directly and went to the social services director, who was busy and deferred the notification. The social services director, once free from her family meeting, visited Resident C but did not connect what she found, a tearful resident with care concerns, to an obligation to immediately reach the executive director.
No one made that call on October 15.
The inspection report characterizes the level of harm as minimal harm or potential for actual harm, the lowest tier in the federal harm scale. That classification describes regulatory exposure. It does not describe what Resident C experienced.
She has chronic pain and lives with major depressive disorder. She was wet, which she found embarrassing enough to apologize for. The person providing her care responded by gesturing at her to be quiet, throwing soiled linens on the floor, and voicing her disgust out loud. Then the resident spent the rest of that day being visited by staff who knew something was wrong but did not treat what had happened to her as an emergency.
The occupational therapist saw her crying during a therapy session and passed the concern to someone who was in a meeting. CNA 2, who had seen everything, chose paper over a phone call.
The inspection covers a single resident and a single incident. The citation is narrow: the failure was in reporting speed, not in whether the incident was eventually reported. The executive director did ultimately notify the state. CNA 9's conduct is described in the record but the inspection does not detail what, if any, disciplinary action followed.
What the record does show is the shape of how information moved through the building that day. A resident was mistreated during morning care. A witness wrote it down and slid the paper under doors at night. A therapist flagged distress to a colleague who was occupied. The social services director checked on the resident but did not surface an abuse allegation to the person responsible for acting on one. The director of nursing found out from a note on the floor. The executive director found out from a phone call the next morning, while she was off the clock.
Resident C, meanwhile, told the social services director what had actually happened not on the day it occurred, but the following morning. The inspection record does not say why she waited, or what the night of October 15 was like for her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebrooke Rehabilitation Center from 2025-10-23 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 5, 2026 · Our methodology
STONEBROOKE REHABILITATION CENTER in NEW CASTLE, IN was cited for abuse-related violations during a health inspection on October 23, 2025.
Resident C is cognitively intact.
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.