Castleton Health Care Center: Dignity Violations - IN
That is what a federal inspector found at Castleton Health Care Center on November 6, 2025.
The resident, identified in inspection records as Resident D, had an indwelling urinary catheter bag strapped to his right leg. He told inspectors he had been waiting two hours to be cleaned up. When a nursing assistant finally came to his room at 4:04 p.m., it was only because the inspector was present. The aide, CNA 3, said she had been assigned to care for Resident D on the evening shift and had not been told he needed anything.
She covered him with a sheet. There was no privacy curtain on his side of the room to close.
Resident D's call light had been visible and audible at the nurses' station since at least 3:46 p.m. At 3:50 p.m., a licensed practical nurse entered his room, turned off the light, and left. Nobody cleaned him up. At 3:55 p.m., the inspector observed him still lying there, pants at his knees, door open. At 3:59 p.m., the same LPN was back at the medication cart counting narcotics. Other staff were observed on the unit talking with each other.
Resident D's diagnosis included cerebral palsy and depression. A quarterly assessment completed in September 2025 noted he had moderately impaired cognitive function but was able to make himself understood and understand what was said to him. He understood exactly what was happening to him.
He was not the only resident left waiting that afternoon.
Resident T, a woman diagnosed with muscle weakness and difficulty walking, had her call light answered at 3:44 p.m. by a nursing assistant who was making rounds passing ice water. The aide entered her room, turned off the light, and kept going down the hallway with the ice water cart. Resident T had asked to be helped back to bed.
She waited another hour and a half.
The following day, Resident T told the inspector the wait had been too long and that it had caused her pain. Her quarterly assessment, completed in August 2025, indicated she was cognitively intact. She knew she had been left there. She said so.
The facility's Executive Nurse Consultant, interviewed the evening of November 6, acknowledged that call lights should have been answered promptly, that care should have been provided, and that a privacy curtain should have been available for Resident D. The Executive Director, interviewed the following afternoon, provided the facility's own written policies on resident rights and dignity, which stated that staff shall maintain bodily privacy during personal care, treat residents with respect, and care for residents in a manner that promotes dignity and individuality.
The policies were revised in 2020. The inspection was conducted in 2025.
What the inspector documented was a gap between those two things that no policy revision had closed. A man with cerebral palsy, cognitively aware, lay exposed in an open doorway for over two hours while the staff assigned to care for him counted pills and chatted nearby. A woman in pain waited ninety minutes after asking for help getting to bed.
The deficiency was cited at a level of minimal harm or potential for actual harm. Resident T said it caused her pain. Resident D said he had been waiting two hours. The inspector observed him still lying there, uncovered, at 3:55 p.m.
CNA 3 pulled a sheet over him. That was the care he received.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Castleton Health Care Center from 2025-11-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
CASTLETON HEALTH CARE CENTER in INDIANAPOLIS, IN was cited for violations during a health inspection on November 7, 2025.
That is what a federal inspector found at Castleton Health Care Center on November 6, 2025.
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.