Flatrock River Lodge: Pressure Ulcer Care Fails - IN
The resident, identified in inspection records only as Resident C, was living with chronic obstructive pulmonary disease, heart failure, and kidney failure. She was cognitively impaired and needed staff help with basic hygiene. When inspectors reviewed her clinical file on January 30, 2026, they found a pattern of missing wound assessments that coincided with her ulcers spreading from one leg to two.
On November 11, 2025, a weekly wound assessment noted a blister on her left leg. That was the last documentation of any kind for nearly two weeks. The next wound assessment in her record was dated November 26, and by then she had two venous ulcers on her left leg. Then the documentation stopped again. Nothing from November 27 through December 8. When the next assessment finally appeared, dated December 9, she had two venous ulcers on her left leg and one on her right.
In five weeks, a single blister had become three open wounds across both legs. The gaps in the record made it impossible to know when each wound appeared or how each one changed.
The facility's own skin management policy required weekly assessments for any resident with an open wound area and directed staff to enter all ongoing wound documentation into the appropriate folder in the clinical record. The policy was handed to inspectors by the Clinical Support Nurse the day before the inspection concluded.
The wound tracking failure was not the only lapse documented in Resident C's file.
A nurse practitioner visit on November 12, 2025 noted that she was experiencing behavioral issues. The provider adjusted her medications and directed staff to schedule a follow-up in two to three weeks, or sooner if her condition warranted it. Her care plan reflected those instructions.
Nobody followed up.
Nurse Practitioner 5, interviewed by inspectors at 2:45 p.m. on January 30, confirmed that Resident C had not been seen after the November 12 visit. By the time inspectors were asking questions, more than eleven weeks had passed since that appointment.
Her behavioral care plan, last revised in September 2025, directed staff to make referrals as needed. The November visit had identified a need. The referral, or the return visit, never came.
The inspection, a complaint survey, was completed January 30, 2026. CMS rated the level of harm as minimal harm or potential for actual harm, the lower end of the violation scale. The deficiency was tied to two separate complaint intakes.
What the rating does not capture is the arithmetic of the situation. A woman with failing lungs, a failing heart, and failing kidneys developed wounds on both legs during a period when the people responsible for tracking those wounds were not writing anything down. Her doctor flagged a problem in November and said to come back in two to three weeks. Nobody came back.
By December, the wounds had multiplied.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Flatrock River Lodge from 2026-01-30 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: August 5, 2026 · Our methodology
FLATROCK RIVER LODGE in RUSHVILLE, IN was cited for violations during a health inspection on January 30, 2026.
The resident, identified in inspection records only as Resident C, was living with chronic obstructive pulmonary disease, heart failure, and kidney failure.
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.