Flatrock River Lodge

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to timely document weekly wound assessment and ensure a primary care provider's visit was completed for 1 of 4 residents reviewed for quality of care concerns. (Resident C) Findings include:The clinical record for Resident C was reviewed on 1/39/2026 at 10:15 a.m. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (progressive, lung disease characterized by chronic airway inflammation, narrowed airways, and damaged air sacs-[COPD]), heart failure, and kidney failure. A Quarterly MDS Assessment, dated 9/15/2025, indicated Resident C was cognitively impaired, did not have behaviors, did not reject care, needed staffs' assistance with hygiene, and did not have pressure areas.a. A behavioral care plan, revised 9/22/2025, indicated staff were to make referrals as needed.A provider's visit note, dated 11/12/2025, indicated Resident C was having behavioral issues. The plan of care reflected medication changes and to follow up in two to three weeks or soon if indicated.During an interview, on 1/30/2026 at 2:45 p.m., Nurse Practitioner (NP) 5 indicated Resident C was not seen after 11/12/2025.b. A skin care plan, revised 9/22/2025, indicated Resident C had skin impairments, the interventions included, but were not limited to, inspected skin every shift and reporting changes in the skin.A weekly wound assessment, dated 11/11/2025, indicated Resident C had a blister to her left leg.The clinical record for Resident C lacked a weekly wound assessment from11/12/2025 through 11/25/2025.A weekly wound assessment, dated 11/26/2025, indicated Resident C had two venous ulcers to her left leg.The clinical record for Resident C lacked a weekly wound assessment from 11/27/2025 through 12/8/2025.A weekly wound assessment, dated 12/9/2025, indicated Resident C had two venous ulcers to her left leg and one venous ulcer to her right leg.A policy, entitled Skin Management, was provided by the Clinical Support Nurse on 1/29/2026 at 11:45 a.m. The policy indicated, .When a resident is admitted with or develops a pressure injury or any other open area, immediate treatment will be initiated.A weekly assessment will be done by the nurse and all ongoing wound documentation will be entered into the Pressure-Injury Assessment fold (for any pressure-injuries) or Non-Pressure Wounds folder 3.1-37This citation relates to Intakes 2710696 and

1. 2715782. Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Flatrock River Lodge

904 E 11th St Rushville, IN 46173

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to timely implement inventions of a pressure relieving boots for 1 of 3 residents reviewed for skin condition. (Resident J)Findings include:The clinical record for Resident was reviewed on 1/30/2026 at 2:05 p.m. The resident's diagnoses included, but were not limited to, dementia (decline in mental abilities) and adult failure to thrive (a decline in physical and mental wellbeing).

A skin care plan, revised 1/4/2026, indicated Resident J had an condition on her left heel which progressed to an unstageable ulcer on 12/24/2025. The intervention for the resident's area to the left heel, included staff were to apply heel protectors to both feet while in bed. A nursing assessment, dated 12/24/2025, indicated the area to Resident J's left heel had increased in size from 1.4 x (by) 1.8 cm on 12/17/2025 to 2.4 x 2.9 cm. The interventions, included but were not limited to, use of heel protector boots. A physician's order, dated 12/26/2025, indicated a request for routine treatment. The order was addressed on 12/29/2025 with a response of dressing order as well as, .Apply heel protectors when not up in wc [wheelchair]. The treatment administration record for Resident J, dated December 2025, indicated heel protectors were not started until 12/31/2025. During an interview, on 1/30/2026 at 3:05 p.m., the Clinical Support Nurse 6 indicated it was the expectations that new orders are processed as soon as possible, but at least within 24 hours. A policy, entitled Prescriber Medication Order, was provided by the Director of Nursing on 1/30/2026 at 3:30 p.m. The policy indicated for new handwritten orders, .the nurse on dity at the [NAME] the order is received enter it on the physician order sheet. This citation relates to Intakes 2710696 and 2715782. 3.1-40

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Flatrock River Lodge

904 E 11th St Rushville, IN 46173

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to timely follow up on fall interventions (Resident D) and notify

a family of a fall (Resident E) for 2 of 3 residents reviewed for falls. Findings include:1. The clinical record for Resident D was reviewed on 1/29/2026 at 2:45 p.m. The resident's diagnoses included, but were not limited to, diabetes and dementia (decline in mental abilities).A Quarterly MDS, dated [DATE REDACTED], indicated Resident D was cognitively intact and needed assistance of staff for transferring with activities of daily living.A incident note, dated 12/23/2025, indicated Resident D had a fall in her room. The immediate intervention indicated, .Requested for OT Eval and Bed Mobility.A physician's order, signed 12/29/2025, indicated for Resident was to have an Occupation Therapy evaluation and treatment as indicated related to her rolling out of bed.During an interview, on 1/29/2026, the Clinical Support 6 indicated the therapy evaluation was not completed and she could not find documentation as to why it was not completed.A nursing note, dated 1/30/2026, indicated that the therapy evaluation was not completed, but was reordered due to her decline

after chronic illness.2. The clinical record for Resident E was reviewed on 1/29/2026 at 3:15 p.m. The resident's diagnoses included, but were not limited to, kidney disease (a condition where the kidneys were damaged or cannot filter blood properly) and tachycardia (a heart rate that exceeds 100 beats per minute in adults while at rest).An admission MDS Assessment, dated 11/3/2025, indicated Resident E was cognitively impaired and needed assistance of staff with transferring for activities of daily living.A fall care plan, dated 11/5/2025, indicated Resident E needed assistance of two staff members for transferring.An incident note, dated 11/4/2025, indicated Resident E had a fall in her room. Under family/contact notification, the documentation stated .Res. is own Responsible Party.During an interview, on 1/29/2026 2:50 p.m., Family Member 4 indicated she was only aware of two falls for her family member during the resident's stay at the facility.A policy, entitled Fall Assessment and Prevention Protocol, was provided by the Clinical Support Nurse 6 on 1/29/2026 at 11:45 a.m. The policy indicated, If/when a resident experiences a fall, a root cause analysis will be conducted to assist in planning appropriate evidence-based interventions to prevent further falls. and .Notify the POA or other legal representative.3.1.45(a)This citation relates to Intakes 2710696 and 2715782.

Event ID:

Facility ID:

If continuation sheet