Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebrooke Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and cognitive intactness reported that a CNA was rough and rushed during incontinence care, causing discomfort and feelings of disrespect. Despite informing staff, no grievance was filed, resulting in a failure to uphold the resident's right to dignified care.
Two residents experienced verbal abuse from CNAs during care, including rude language, silencing gestures, and the use of profanities. Both residents, who had significant medical and cognitive needs, were left distressed by these interactions, which were corroborated by staff interviews and facility records.
A resident with chronic pain syndrome, major depressive disorder, and hypertension, who was cognitively intact, experienced alleged verbal abuse by a CNA. The incident was not immediately reported to the ED as required by facility policy; instead, a written statement was submitted to directors the following day, delaying proper notification and investigation.
A resident with stage 2 pressure ulcers and severe cognitive impairment was observed sitting in a wheelchair without the required pressure redistribution cushion, despite care plan and policy directives. The cushion had been removed for cleaning and left on the floor, and staff did not ensure its timely replacement, resulting in noncompliance with wound prevention protocols.
Two residents did not receive ordered nutritional interventions: one was not provided with a required adaptive drinking device, resulting in difficulty consuming fluids, and another was not weighed as ordered despite significant recent weight loss. Staff failed to follow physician orders and facility policy regarding adaptive equipment and weight monitoring, and documentation of refusals or attempts was lacking.
Two residents with severe cognitive impairment and dementia were observed engaging in intimate behaviors, including kissing and unsupervised time together in their shared room, without effective staff intervention. Staff were unsure of the appropriate care plan interventions, and the facility lacked a dementia care policy, resulting in a failure to address the residents' behaviors as required.
A resident with pressure ulcers, who was dependent on staff for toileting, received incontinence care during which CNAs placed soiled washcloths directly on the bed sheet instead of immediately bagging them. The soiled fitted sheet was not changed after care, and later, dried stool was found on the sheet and a washcloth was left in the windowsill. Staff interviews confirmed that proper infection control protocols for handling soiled linens were not followed.
Two residents with severe cognitive impairment and dependence on staff for ADLs did not receive showers as preferred, despite care plans and documented preferences indicating the importance of showers. Instead, both residents were given bed baths on multiple occasions, and staff and family interviews confirmed the residents' preferences were known but not consistently honored.
A resident with advanced dementia, heart failure, and malnutrition experienced a significant decline in eating and drinking abilities, requiring staff assistance with meals. Despite ongoing monitoring for weight loss, staff failed to consistently document the resident's meal intakes over several weeks, with numerous missing entries for breakfast, lunch, and dinner, contrary to facility procedures.
The facility failed to maintain a clean and sanitary kitchen, with issues such as incorrect use-by dates, undated food items, improper storage of boxes on the floor, and moldy buns. These deficiencies persisted over several days and had the potential to affect all 72 residents receiving food from the kitchen.
The facility failed to maintain resident rooms in good repair, with issues such as peeling cove base, missing paint, and damaged headboards observed in multiple rooms. The Maintenance Director acknowledged the ongoing problem and noted that staff actions contributed to the damage, despite a training program being in place.
The facility failed to complete a Minimum Data Set (MDS) Assessment for a resident discharged from hospice services. Despite the facility's policy requiring a significant change assessment, no such assessment was completed in October 2023. The MDS Coordinator acknowledged the oversight.
The facility failed to accurately indicate hospice services for a resident with Alzheimer's and did not correctly code oxygen therapy for two residents with chronic conditions. The MDS assessments did not reflect the actual care being provided, leading to discrepancies in the residents' records.
The facility failed to continue treatment for a resident with pressure ulcers and did not implement necessary interventions for pressure ulcer prevention and treatment for three residents. One resident did not receive prescribed Medihoney treatment for several days, another had a reddened ear due to lack of ear protectors on oxygen tubing, and a third resident's heels were not consistently offloaded, leading to pressure areas.
A resident with a history of falls and multiple health conditions fell out of bed because the prescribed bedside mat was not in place, resulting in skin tears. The facility's Fall Management Policy was not adequately followed.
The facility failed to ensure a dietary staff member did not work while experiencing gastrointestinal illness symptoms and did not wait 48 hours after symptoms stopped before returning to work. The staff member returned to work the next day to handle food, contrary to facility policy and CDC guidelines.
The facility failed to provide an ongoing activity program for two residents in the dementia care unit. Staff and family members confirmed that the unit had been without an activity assistant since June 2023, leading to residents sitting idle. The facility did not have a specific dementia care policy, and documentation showed no activity participation for the past three months.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
A resident reported that a CNA failed to provide dignified incontinence care by being rough and rushing during care, which resulted in the resident feeling sore and disrespected. The resident stated that she had communicated her concerns directly to the CNA, asking him to be gentler, but the behavior did not change. She also reported the issue to a nurse and other CNAs, but was unable to identify their names. Despite these reports, no grievance was filed on her behalf regarding the matter. The resident was cognitively intact and able to make reasonable and consistent decisions, with no behavioral issues noted. She had multiple complex medical diagnoses, including heart failure, respiratory failure, COPD, diabetes, and morbid obesity, and was frequently incontinent of urine and always incontinent of bowels. Facility policy, as provided by the Executive Director, states that residents have the right to be treated with dignity and respect, including during personal care. The failure to provide dignified care and to address the resident's grievance led to the deficiency.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by two separate incidents involving two residents. In the first case, a resident with diagnoses including lymphedema, hypertensive heart disease, and PTSD, who was cognitively intact but dependent on staff for toileting, reported that a CNA entered her room in an upset manner, spoke to her rudely, repeatedly told her to be quiet, and used hand gestures to silence her while providing incontinence care. This interaction left the resident tearful and apologetic for her condition, and was corroborated by another CNA, the occupational therapist, and the social service director, all of whom observed or were informed of the resident's distress following the incident. In the second case, a resident with multiple diagnoses including bipolar disorder, major depressive disorder, anxiety, traumatic brain injury, and hemiplegia, who was moderately impaired in decision-making and dependent on staff for mobility and toileting, was subjected to harsh language and cursing by a CNA during care. The incident was witnessed by another CNA, who reported hearing the staff member use profanities towards the resident. The facility's records confirmed the incident and indicated that the staff member was suspended during the investigation and subsequently terminated for resident abuse or neglect. Both incidents demonstrate a failure to maintain an environment free from verbal and mental abuse as required by facility policy.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an incident of alleged verbal abuse involving a resident with chronic pain syndrome, major depressive disorder, and hypertension, who was cognitively intact. On the day of the incident, a CNA observed another CNA hush the resident, make hand gestures for her to stop talking, and throw dirty linens on the floor while making a derogatory comment about being soiled. The CNA who witnessed the event wrote a statement and placed it under the doors of all directors that night, resulting in the report being received the following day. The CNA acknowledged that the Executive Director (ED) should have been notified sooner. Other staff, including an Occupational Therapist (OT) and the Social Service Director (SSD), became aware of the resident's distress on the same day, but the resident did not disclose the details of the incident to the SSD until the next day. The Director of Nursing (DON) and the ED were not made aware of the alleged abuse until the morning after the incident, when they received the written statement. The facility's abuse policy required immediate notification of the charge nurse and the ED when abuse is witnessed or suspected, which was not followed in this case.
Failure to Provide Pressure Redistribution Cushion for Resident with Pressure Ulcers
Penalty
Summary
A deficiency occurred when staff failed to ensure that a pressure redistribution cushion was in place for a resident with stage 2 pressure ulcers. The resident, who had diagnoses including dementia, repeated falls, and chronic pain syndrome, was identified as being at risk for pressure ulcers and required a pressure-reducing device for her chair according to her care plan. Observations revealed that the resident's chair cushion was not in use and was instead found on the floor beside the chair on two separate occasions. The resident's daughter reported that the cushion had been soiled the previous day, and staff had removed the cover for washing, leaving the cushion on the floor. Further review of the resident's clinical record and care plan confirmed the need for a Roho cushion in the chair or wheelchair as an intervention to prevent skin breakdown. Despite this documented requirement, the resident was observed sitting in a wheelchair without the necessary cushion, and the facility's policy stated that all residents utilizing a wheelchair should have a pressure redistribution cushion. The Executive Director confirmed that it was nursing's responsibility to ensure the cushion was in place.
Failure to Provide Ordered Nutritional Support and Monitoring
Penalty
Summary
The facility failed to ensure that two residents received appropriate nutritional care as ordered. One resident with diagnoses including hemiplegia, hemiparesis, and malnutrition was observed during a meal without the prescribed adaptive drinking device (nosey cup). Instead, the resident was provided a regular cup, resulting in difficulty drinking, with most of the liquid spilling onto the resident's chin and napkin. The LPN confirmed that the nosey cup was not provided and was not listed on the meal ticket, despite a physician's order and facility policy requiring adaptive devices to be supplied as ordered. Another resident with Alzheimer's disease and a history of significant weight loss was not weighed bi-weekly as ordered by the physician. The clinical record showed missing weight documentation for an entire month, and there was no record of refusals or attempts to obtain the weight. The resident's care plan identified them as being at nutritional risk and required weight monitoring, but this intervention was not consistently implemented. The DON acknowledged that nursing staff were responsible for obtaining and documenting weights and refusals, but could not explain the lack of documentation.
Failure to Implement Interventions for Intimate Behaviors in Residents with Dementia
Penalty
Summary
The facility failed to implement appropriate interventions for two residents with dementia who were observed engaging in intimate behaviors, including kissing and holding hands, in the memory care unit's common area. Staff, including a CNA and an RN, were aware of the behaviors but were either unsure of the care plan interventions or unable to intervene effectively. The residents, both diagnosed with Alzheimer's disease, dementia, and other mental health conditions, were severely impaired in daily decision-making and had a history of wandering that intruded on the privacy of others. Despite being care planned for behaviors, staff could not identify or implement specific interventions during the observed incidents. During the observation period, the two residents continued to hold hands and enter their shared bedroom unsupervised with the door shut for at least 25 minutes, without staff intervention. The Memory Care Coordinator and other staff expressed uncertainty about how to address the situation, noting that this specific behavior had not been previously observed. Additionally, the facility lacked a dementia care policy, and there was confusion among staff regarding access to care plans and the appropriate use of dementia care training to manage such behaviors.
Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection control measures during incontinence care for a resident with pressure ulcers. The resident, who was severely cognitively impaired, at risk for pressure ulcers, and dependent on staff for toileting, was observed receiving care from two CNAs. Both CNAs donned gowns and gloves due to the resident being on Enhanced Barrier Precautions for wounds. During the cleaning process, soiled washcloths were placed directly onto the resident's fitted bed sheet instead of being immediately bagged. After cleaning, the soiled pad was removed and replaced, but the fitted sheet, which had come into contact with the soiled washcloths, was not changed. The resident was then covered with a clean sheet over the unchanged fitted sheet. Later, a washcloth with dried stool was found in the resident's windowsill, and smears of dry stool were observed on the fitted bed sheet. Interviews with staff confirmed that soiled linens and washcloths should have been placed in a plastic bag after use and that the soiled sheet should have been changed and bagged for transport to the soiled utility room. The facility's perineal care competency checklist also indicated that a plastic bag should be available for soiled linens, but this protocol was not followed during the observed care.
Failure to Provide Showers According to Resident Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not providing showers as preferred for two residents who were dependent on staff for activities of daily living (ADLs). Resident B, with diagnoses including diabetes mellitus, major depressive disorder, anxiety disorder, glaucoma, cataract, hearing loss, and anorexia, was assessed as severely impaired for daily decision making and required staff assistance for showers. Documentation indicated that it was very important for this resident to have showers, and the care plan specified showers twice weekly. However, shower reports showed that Resident B received complete bed baths instead of showers on multiple occasions across March, April, and May, despite the resident's stated preference and care plan interventions. Similarly, Resident E, who had dementia, chronic kidney disease, repeated falls, and chronic pain syndrome, was also severely cognitively impaired and dependent on staff for showering. The care plan and preference documentation indicated a preference for showers twice weekly. Despite this, shower reports revealed that Resident E received bed baths instead of showers on several documented dates in April and May. Interviews with staff and family confirmed awareness of the residents' preferences, but the facility did not consistently provide showers as preferred.
Failure to Consistently Document Meal Intake for High-Risk Resident
Penalty
Summary
The facility failed to consistently document meal intakes for a resident with significant medical concerns, including vascular dementia, heart failure, and moderate protein-calorie malnutrition. The resident was identified as severely cognitively impaired, required supervision or assistance with meals, and had experienced notable weight loss in the previous six months. Staff interviews confirmed that the resident had a marked decline in eating and drinking abilities prior to being sent to the hospital, with minimal intake even when fed by staff. The interdisciplinary team, including the Registered Dietitian and Certified Dietary Assistant, documented significant weight loss and ongoing monitoring for this issue. A review of the resident's meal intake records for February and March revealed numerous instances where meal consumption was not documented, including multiple days with missing entries for breakfast, lunch, or dinner. The facility's procedure required nursing staff to document the percentage of food consumed after each meal, but this was not consistently followed. The lack of routine documentation occurred despite the resident's high risk for nutritional decline and ongoing monitoring for weight loss.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, as evidenced by multiple observations of improper food storage and handling. During a kitchen tour, a holding refrigerator was found to contain a container of diced ham with an incorrect use-by date, a prepared salad with undated cubed ham, and undated bacon bits. Additionally, multiple boxes were stored on the floor of the main freezer and dry storage room. A bulk storage bin contained a plastic cup in contact with a food substance, and moldy buns were found on a rack outside the kitchen. These issues persisted over several days, despite being noted in multiple observations. The Dietary Manager was interviewed and indicated that the facility was aware of some of the issues, such as the need to discard the bulk storage bin and the lack of space in the freezer. However, the manager was unaware of the moldy buns. The facility's food storage policy, which requires food to be stored off the floor, properly labeled, and within specified time frames, was not followed. This failure had the potential to affect all 72 residents who receive food from the kitchen.
Facility Failed to Maintain Resident Rooms in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were in good repair, specifically related to the walls, headboard, and cove base in the bathrooms for six residents. Observations noted peeling cove base in one resident's bathroom, missing paint alongside the walls behind the headboards in multiple rooms, and a flexible strip of material hanging down from a headboard onto a resident's bed. These issues were confirmed during an environmental tour with the Maintenance Director and Housekeeping Supervisor, who acknowledged the ongoing problem with wall repairs and the impact of staff actions on the condition of the walls. The Maintenance Director indicated that the facility has a system for nursing staff and housekeeping to input work orders for environmental concerns, which are then directed to him. However, he noted that the repairs are limited by the amount of work he is allowed to conduct monthly. Despite implementing a training program for staff regarding the proper placement of beds to prevent damage, the problem persists, and approval for further repairs is pending.
Failure to Complete MDS Assessment for Resident Discharged from Hospice
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Assessment for a resident who was discharged from hospice services. The clinical record for the resident, who had a medical diagnosis of dementia, indicated that she was discharged from hospice services on October 12, 2023. However, no significant change MDS Assessment was completed for the resident in October 2023, despite the facility's policy requiring such an assessment when a terminally ill resident enrolls or revokes hospice program. The MDS Coordinator acknowledged that the Significant Change Assessment for the resident was missed.
Inaccurate MDS Assessments for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to accurately indicate the use of hospice services for one resident and failed to accurately code oxygen therapy for two residents. Resident 43, diagnosed with Alzheimer's disease, had an Annual MDS Assessment that did not reflect the resident's 6-month prognosis or hospice services, despite a hospice certification indicating terminal illness and a life expectancy of less than six months. The MDS nurse admitted to not completing a significant change assessment due to confusion over the payor source for hospice services. Resident 10, who had diagnoses including pneumonia, chronic respiratory failure, emphysema, and high blood pressure, was observed receiving oxygen therapy through a nasal cannula. However, the Admission MDS assessment did not indicate that the resident received oxygen therapy. Similarly, Resident 65, diagnosed with dementia, high blood pressure, anemia, and atrial fibrillation, was observed using oxygen therapy, but the Quarterly MDS assessment did not reflect this. The MDS Coordinator acknowledged the inaccuracies and stated she would enter modifications to correct the records.
Failure to Ensure Continuation of Pressure Ulcer Treatment and Prevention
Penalty
Summary
The facility failed to ensure continuation of treatment for a resident with pressure ulcers and did not implement necessary interventions for pressure ulcer prevention and treatment for three residents. Resident 55, who had multiple pressure ulcers, did not receive the prescribed Medihoney treatment for the right heel and left buttock from 3/6/24 to 3/12/24. The Director of Nursing confirmed the absence of treatment orders during this period, and the resident was under hospice care starting 3/2/24, with hospice conducting a comprehensive review of the resident's orders. Resident 10, who was on oxygen therapy, did not have ear protectors on the oxygen tubing as ordered, resulting in a reddened area on the right ear. The resident reported soreness, and an LPN assessed the ear, confirming the redness and placing a temporary tissue pad. Resident 136, who had developed pressure areas on both heels, was observed with her heels touching the bed due to a sliding pillow. The care plan indicated the use of a heel offloading pillow, but the resident's heels were not consistently offloaded. An LPN confirmed the presence of a blister on the left heel and the need for regular monitoring and dressing changes.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were in place after a fall had occurred for a resident. The resident had a history of falls and was at risk due to conditions such as cerebral infarction, hemiplegia, dementia, glaucoma, and weakness. The care plan included the use of a bedside mat while resting in bed, which was initiated on a specific date. However, during a fall event, the resident fell out of bed while sleeping, and the mat was not at the bedside. The incident resulted in the resident sustaining skin tears. The facility's Fall Management Policy required specific care plan interventions to address each resident's fall risk factors, but these were not adequately implemented in this case.
Failure to Adhere to Infection Control Policies
Penalty
Summary
The facility failed to ensure a dietary staff member did not work while experiencing signs and symptoms of a gastrointestinal illness and did not ensure 48 hours had passed since symptoms started. During a kitchen tour, it was noted that the Dietary Manager was out ill. An interview with the Dietary Manager revealed that she had symptoms of a gastrointestinal illness while at work and went home, but returned to work the next day to handle food. The facility's policy requires employees to consult the Director of Nursing Services or Infection Preventionist before returning to work after an infectious illness and to provide a physician's statement of fitness. The CDC guidelines also state that individuals should not handle food or provide healthcare for at least 48 hours after symptoms stop. The facility did not adhere to these guidelines, leading to the deficiency.
Lack of Ongoing Activity Program in Dementia Care Unit
Penalty
Summary
The facility failed to provide an ongoing activity program on the dementia care unit for two residents, Resident C and Resident D. Interviews with staff members, including CNAs and the Dementia Care Coordinator, revealed that the dementia care unit had been without an activity assistant since June 2023. Staff members did their best to provide activities, such as self-initiated packets and coloring, but these efforts were insufficient. The Dementia Care Coordinator was overburdened with multiple roles, including social services and activities, until a new activity assistant was hired in late February 2024. Interviews with family members of Resident C and Resident D confirmed the lack of activities, with residents often sitting idle in the dining room. Resident C's family member noted that the resident had severe cognitive impairment and enjoyed activities like sewing, bingo, and socialization, but these were not provided. Similarly, Resident D's family member expressed dissatisfaction, stating that the facility had promised various activities, but none were provided until recently. Resident D also had severe cognitive impairment and enjoyed activities like cooking, playing with her dog, and being outside, which were not facilitated by the facility. The facility's failure to provide adequate activities was further corroborated by the lack of documentation showing Resident C and Resident D's participation in any activities for the past three months. The Administrator confirmed that the facility did not have a specific dementia care policy and followed state guidelines for dementia training. The Director of Nursing provided an activity policy stating that the facility would offer an ongoing program of activities to meet the residents' interests and well-being, but this was not implemented effectively. This deficiency relates to Complaint IN00430463.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Castle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of New Castle, The | 0.1 mi | ★★★★★ | 8 | 0 |
| Hickory Creek At New Castle | 0.1 mi | ★★★★★ | 9 | 0 |
| Willows Of New Castle | 0.2 mi | ★★★★★ | 10 | 0 |
| Glen Oaks Health Campus | 3.1 mi | ★★★★★ | 11 | 0 |
| Middletown Nursing And Rehabilitation Center | 12.1 mi | ★★★★★ | 10 | 0 |
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