Glen Oaks Health Campus: Unreported Death Injury - IN
When he looked more closely, he found the reason. Above her left eye, on the middle left side of her forehead, there was an open wound approximately two inches in diameter. It had exposed her skull. Tissue and blood were visible.
The woman, identified in inspection records only as Resident B, had been found on the bathroom floor without a pulse earlier that morning, a small amount of blood noted beneath her head. She had a prosthetic heart valve, a history of pulmonary embolism, and according to her medical records, was cognitively intact. She used a walker or wheelchair to get around. She needed some help getting to the toilet. Her chart flagged her as a fall risk.
Glen Oaks never reported her fall or her injuries to the Indiana Department of Health.
The facility's Director of Health Services and Executive Director told inspectors on April 28 that they had consulted with the medical director and concluded the fall resulted from a cardiac event. Because they believed the death had a cardiac explanation, they decided no report was necessary. They did not mention the wound to state health authorities. They did not mention it at all.
It was the family who found it.
After Resident B's body was transferred to the funeral home, her family examined her more carefully than anyone at the facility apparently had. They found what the funeral director's written report, dated April 20, described as a large open wound to the forehead above the left eye, approximately two inches in diameter, exposing the skull. The intern who picked up the body documented what he saw. The funeral director submitted a written report. Photographs were eventually provided to inspectors on April 29.
Those photographs showed a deep cut on the middle left side of the forehead, just before the hairline, where a quarter-sized area of tissue and blood remained visible.
The coroner told inspectors a different story than the one the facility had apparently constructed. He said he was called by EMS on the morning of April 16 and told he did not need to come to the scene. Nothing was suspicious, he was informed. Nothing was unnatural. He stayed away. He learned about the wound later, the same way the family did, after the body had already left Glen Oaks.
The facility's own progress note from 6:15 a.m. on April 16 recorded that Resident B was found on the bathroom floor without a pulse, with a small amount of blood under her head. "A small amount of blood." The wound the funeral home intern found when he arrived to collect her body was two inches wide and had exposed bone.
What happened in the hours between that progress note and the intern's arrival is not addressed in the inspection record. What is documented is that by the time anyone outside the facility examined Resident B's body with any care, she had a shower cap over her head.
The inspection, a complaint investigation completed April 28, cited Glen Oaks for failing to report a fall with injuries of unknown source to the Indiana Department of Health. The harm level was classified as minimal harm or potential for actual harm. One of three residents reviewed for reporting was affected.
That classification, minimal harm, applies to the regulatory violation, the failure to file a report. Resident B was already dead.
The question the inspection record raises but does not answer is simpler than any regulatory category: how does a woman die with a two-inch skull-exposing wound to her forehead, and the people responsible for her care describe it, in writing, as a small amount of blood?
The Director of Health Services and Executive Director, interviewed together on the morning of April 28, told inspectors that the medical director's involvement gave them confidence in their interpretation. A cardiac event. No report needed. The wound, which the funeral home intern would document in detail four days later, apparently did not factor into that conclusion in any way that reached state health authorities.
Indiana requires nursing facilities to report falls with injuries of unknown source. The classification matters because it triggers outside review, the kind of review that might ask how a resident sustained a wound large enough to expose her skull in a bathroom fall, or whether the circumstances of her death warranted a coroner's investigation rather than a phone call from EMS telling the coroner to stand down.
The coroner did not investigate the scene. He was told there was nothing suspicious. Nothing unnatural.
Resident B's admission assessment, completed February 27, noted she was at risk for falls. It noted she needed partial or moderate assistance with toileting. She was going to the bathroom. She was at a facility that knew she might fall. She fell. She died. And the people who found her, who wrote down "small amount of blood," who placed a shower cap over her head, decided on their own that the state did not need to know.
The family went to the funeral home and found a wound that no one at Glen Oaks had seen fit to describe accurately, report officially, or allow the coroner to examine in person. The funeral director wrote it up. The intern documented it. Photographs were taken.
Those photographs exist because a family looked at their loved one's body and knew that what they were seeing did not match what they had been told.
Glen Oaks Health Campus is located at 601 W County Road 200 S in New Castle. The inspection was conducted by the Centers for Medicare and Medicaid Services. The facility's plan of correction, if any, can be obtained from the nursing home or the Indiana State Survey Agency.
What cannot be corrected is the timeline. Resident B died on April 16. The coroner was told not to come. The state was never called. The wound was found by a funeral home intern on his way to collect her body, hidden under a shower cap, twelve days before a federal inspector ever walked through the door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glen Oaks Health Campus from 2026-04-28 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 19, 2026 · Our methodology
GLEN OAKS HEALTH CAMPUS in NEW CASTLE, IN was cited for violations during a health inspection on April 28, 2026.
When he looked more closely, he found the reason.
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.