Resident C, who suffered from chronic obstructive pulmonary disease, heart failure, and kidney failure, developed the wounds between November and December 2025. The facility's own skin management policy required immediate treatment and weekly assessments for any open areas.
But the clinical record showed significant gaps in monitoring.
On November 11, 2025, staff documented a blister on Resident C's left leg during a weekly wound assessment. The next assessment wasn't completed until November 26 — a two-week gap during which the resident's condition worsened dramatically.
By November 26, the single blister had become two venous ulcers on the left leg.
Staff again failed to complete weekly assessments from November 27 through December 8. When they finally documented another assessment on December 9, Resident C had developed a third venous ulcer, this time on the right leg.
The deterioration occurred despite a care plan requiring staff to inspect the resident's skin every shift and report changes. A quarterly assessment from September indicated Resident C was cognitively impaired and needed assistance with hygiene, but had no pressure areas at that time.
The missed wound assessments coincided with other care lapses. Resident C was also experiencing behavioral issues that required medical attention, but never received promised follow-up visits from her primary care provider.
A provider's visit note from November 12, 2025, documented the behavioral problems and outlined medication changes. The plan called for follow-up in two to three weeks or sooner if needed.
No follow-up occurred.
Nurse Practitioner 5 confirmed during a January 30 interview that Resident C was not seen again after the November 12 visit, despite the provider's own recommendations for continued monitoring.
The facility's skin management policy, provided to inspectors by the Clinical Support Nurse, explicitly stated that when residents develop open areas, "immediate treatment will be initiated" and "a weekly assessment will be done by the nurse."
The policy directed that all wound documentation be entered into specific folders for tracking purposes. But the clinical record showed no assessments during the critical periods when Resident C's condition was deteriorating.
Resident C's case illustrates how documentation failures can mask worsening medical conditions. The resident had multiple serious health conditions including progressive lung disease and organ failure that required careful monitoring.
A behavioral care plan revised in September 2025 directed staff to make referrals as needed, suggesting the facility was aware of Resident C's complex medical and behavioral needs.
The inspection was conducted in response to complaints about the facility. Inspectors reviewed four residents for quality of care concerns and found the documentation and provider visit failures affected Resident C specifically.
Federal regulations require nursing homes to provide treatment and care according to physician orders and residents' individual needs. The citation noted minimal harm or potential for actual harm to residents.
Flatrock River Lodge operates at 904 E 11th Street in Rushville, about 35 miles southeast of Indianapolis. The facility must submit a plan of correction addressing how it will ensure timely wound assessments and provider visits going forward.
The inspection findings relate to two separate complaint intakes filed with state regulators, suggesting multiple concerns about care quality at the facility.
Resident C's wounds progressed from a single blister to three ulcers across different limbs during the periods when required weekly assessments were not completed, demonstrating the potential consequences when facilities fail to follow their own policies for monitoring vulnerable residents.
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.