Inspection Report Summary
The most recent inspection on April 28, 2025, identified several deficiencies related to Life Safety Code requirements, including documentation and maintenance of emergency lighting, sprinkler systems, fire extinguishers, fire dampers, fire drills, electrical receptacles, and generator testing. Earlier inspections showed a pattern of Life Safety Code issues, such as problems with fire doors, sprinkler maintenance, and emergency preparedness, as well as some resident care deficiencies involving compression stocking use and skin assessments. Complaint investigations were mostly unsubstantiated, except for one substantiated complaint in August 2022 regarding staff not properly using personal protective equipment during COVID-19 testing, which resulted in a cited deficiency. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows ongoing challenges with Life Safety Code compliance, with some fluctuations but no clear overall improvement or worsening trend.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
44% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Census: 28
Capacity: 63
Deficiencies: 8
Apr 28, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency lighting documentation, sprinkler system maintenance, fire extinguisher inspections, fire damper inspections, fire drills timing, electrical receptacle replacements, and generator load testing documentation.
Severity Breakdown
SS=F: 5
SS=D: 2
SS=E: 1
SS=C: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to document monthly and annual testing for all battery backup emergency lights as required by LSC 7.9. | SS=F |
| Failed to maintain ceiling construction outside of kitchen in accordance with NFPA 13; missing escutcheon exposing interstitial space above sprinkler. | SS=D |
| Failed to document sprinkler system inspections including monthly gauge and valve inspections as required by NFPA 25. | SS=F |
| Failed to ensure 1 of 20 portable fire extinguishers were inspected monthly with documented date and initials as required by NFPA 10. | SS=E |
| Failed to ensure all fire dampers were inspected and maintained within the most recent four year period as required by NFPA 90A and NFPA 80. | SS=F |
| Failed to conduct quarterly fire drills at unexpected times under varying conditions on the first shift for three of four calendar quarters. | SS=C |
| Failed to replace nonhospital-grade electrical receptacles that failed annual testing in 2 resident rooms with hospital-grade receptacles as required by NFPA 70. | SS=D |
| Failed to document complete written record of monthly generator load testing for 5 months of the most recent 12 month period as required by NFPA 110. | SS=F |
Report Facts
Certified beds: 63
Census: 28
Fire dampers inspected: 30
Fire drills missing unexpected timing: 3
Electrical receptacles failed: 2
Generator load testing months missing documentation: 5
Generator rating: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leah Staley Hillenburg | Clinical and Quality Consultant | Named during exit conference and report signature |
Inspection Report
Renewal
Census: 33
Capacity: 33
Deficiencies: 1
Apr 10, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on April 7, 8, 9, and 10, 2025.
Findings
The facility was found deficient for failing to ensure a resident had compression stockings on as ordered. Specifically, Resident 9 did not have TED hose applied as ordered on multiple occasions, despite physician orders and treatment administration records indicating otherwise.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident 9 had compression stockings (TED hose) on as ordered for edema. | SS=D |
Report Facts
Census: 33
Total Capacity: 33
Medicare residents: 5
Medicaid residents: 24
Other payor residents: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Smyth | RDO | Laboratory Director or Provider/Supplier Representative who signed the report |
Inspection Report
Renewal
Deficiencies: 0
Apr 10, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure survey completed on April 10, 2025.
Findings
Flatrock River Lodge was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper compliance review for Recertification and State Licensure.
Inspection Report
Follow-Up
Census: 39
Capacity: 63
Deficiencies: 0
May 28, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/05/24.
Findings
At the PSR Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, the facility was found in compliance with Life Safety from Fire and related regulations.
Report Facts
Certified beds: 63
Census: 39
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Apr 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431241.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00431241 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 8
Census Payor Type - Medicare: 0
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 11, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure completed on March 8, 2024.
Findings
Flatrock River Lodge was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure.
Inspection Report
Life Safety
Census: 33
Capacity: 63
Deficiencies: 7
Apr 5, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements including issues with exit discharge surfaces, self-closing fire doors, sprinkler system maintenance, corridor door closures, and annual fire door inspections. Emergency preparedness policies were found substantially compliant with updates needed for agreements with other facilities.
Severity Breakdown
SS=C: 1
SS=E: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Emergency preparedness policies failed to ensure updated arrangements with other LTC facilities and providers to receive residents in case of limitations or cessation of operations. | SS=C |
| Exit discharge from the 200 Hall Exit had an uneven concrete rise and was not a level walking surface free of obstructions. | SS=E |
| One hazardous area door (Activities Office) lacked a properly working self-closing device. | SS=E |
| Sprinkler system piping had wire draped over pipes, violating NFPA 25 requirements. | SS=E |
| One corridor door to the Activities Office did not close and latch properly to resist smoke passage. | SS=E |
| One corridor door to the dietary hall was propped open with a cardboard doorstop, preventing proper closure and latching. | SS=E |
| Annual inspection and testing documentation was not available for the fire door assembly at the Oxygen Transfilling room. | SS=E |
Report Facts
Certified beds: 63
Census: 33
Residents affected: 12
Residents affected: 20
Staff affected: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leah Staley Hillenburg | HFA | Signed report as Laboratory Director or Provider/Supplier Representative |
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including emergency preparedness, exit discharge, sprinkler piping, and door issues | |
| Acting Administrator | Interviewed and acknowledged multiple deficiencies including emergency preparedness, exit discharge, sprinkler piping, and door issues | |
| Corporate COO | Present at exit conference and acknowledged findings |
Inspection Report
Renewal
Census: 34
Capacity: 34
Deficiencies: 2
Mar 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 4 to March 8, 2024.
Findings
The facility was found deficient in completing accurate skin assessments and providing treatment for a resident with bilateral foot and ankle swelling, and in properly dating food items stored in the walk-in refrigerator. Corrective actions and staff re-education were planned and implemented.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to complete an accurate skin assessment and provide treatment for a resident experiencing bilateral foot and ankle swelling. | SS=D |
| Failed to date open and/or prepare food products in the walk-in refrigerator, risking food safety. | SS=F |
Report Facts
Census: 34
Total Capacity: 34
Residents affected: 1
Residents affected: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Smyth | RDO | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419074.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00419074 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 31
Total Capacity: 31
Medicaid Census: 23
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 0
Aug 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413939.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00413939 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 3
Medicaid residents: 21
Other payor residents: 4
Inspection Report
Follow-Up
Census: 33
Capacity: 63
Deficiencies: 0
Apr 21, 2023
Visit Reason
A second Post Survey Revisit (PSR) was conducted to the PSR from 03/09/23 following the Life Safety Code Recertification and State Licensure Survey conducted on 02/02/23 by the Indiana Department of Health.
Findings
At this PSR Life Safety Code survey, Flatrock River Lodge was found in compliance with Medicare/Medicaid participation requirements and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinkled except for a detached garage used for storage.
Inspection Report
Re-Inspection
Census: 34
Capacity: 63
Deficiencies: 1
Mar 9, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on Emergency Preparedness and Life Safety Code Recertification surveys originally conducted on 02/02/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to ensure two hazardous area doors had properly working self-closing devices. The deficiency affected hazardous storage rooms and was acknowledged by the Director of Nursing.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 2 of over 10 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. | SS=E |
Report Facts
Certified beds: 63
Census: 34
Hazardous area doors deficient: 2
Hazardous area doors total: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Smyth | RDO | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing | Interviewed regarding hazardous area door deficiencies and acknowledged findings |
Inspection Report
Renewal
Deficiencies: 0
Feb 28, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the Recertification and State Licensure of the facility.
Findings
Flatrock River Lodge was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure.
Inspection Report
Complaint Investigation
Census: 1
Deficiencies: 0
Jan 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400318.
Findings
The complaint IN00400318 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00400318 was substantiated but no deficiencies related to the allegations were cited.
Inspection Report
Annual Inspection
Census: 1
Capacity: 36
Deficiencies: 6
Jan 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on January 3, 4, 5, 6, 9 & 10, 2023.
Findings
The facility was found to have deficiencies related to resident accommodations, self-determination, quality of care including blood sugar monitoring, accident prevention, psychotropic medication use, and dental services. Plans of correction and reeducation were implemented for all cited deficiencies.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a resident's fluids were in reach for 4 of the 6 survey days affecting 1 resident. | SS=D |
| Failed to ensure a resident's choice for shower times was honored affecting 1 resident. | SS=D |
| Failed to notify physician of low and high blood sugars and failed to assess resident for hypoglycemia and hyperglycemia for 1 of 5 residents reviewed. | SS=D |
| Failed to utilize two staff for transfers, failed to use gait belts during transfers, and failed to implement fall interventions affecting 3 of 5 residents reviewed for accidents. | SS=D |
| Failed to have indication for use, failed to implement behavioral interventions, failed to monitor antipsychotic medication, and failed to provide education on risks for 3 of 5 residents reviewed for unnecessary medication use. | SS=D |
| Failed to provide routine dental services for a resident with poor fitting dentures. | SS=D |
Report Facts
Survey dates: 6
Census Bed Type SNF/NF: 35
Census Bed Type Residential: 1
Total Capacity: 36
Residents affected by fluid reach deficiency: 1
Residents affected by shower time choice deficiency: 1
Residents affected by blood sugar monitoring deficiency: 1
Residents affected by accident prevention deficiency: 3
Residents affected by psychotropic medication deficiency: 3
Residents affected by dental services deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leah Staley Hillenburg | HFA | Signed the report |
| Director of Nursing | Interviewed regarding blood sugar monitoring, fall prevention, and psychotropic medication monitoring | |
| Nurse Practitioner | Interviewed regarding psychotropic medication use for Residents 20, 30, and 4 | |
| Administrator | Interviewed regarding dental services and psychotropic medication education | |
| CNA 1 | Observed assisting with resident care and interviewed regarding resident behaviors | |
| CNA 2 | Observed assisting with resident care and interviewed regarding resident behaviors | |
| CNA 3 | Interviewed regarding resident feeding and fluid intake | |
| CNA 4 | Observed assisting with resident transfer | |
| Activity Director | Interviewed regarding resident shower preferences |
Inspection Report
Annual Inspection
Census: 1
Capacity: 36
Deficiencies: 6
Jan 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on January 3, 4, 5, 6, 9 & 10, 2023.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident needs and preferences were met, failure to notify physicians of abnormal blood sugar readings, inadequate supervision and assistance to prevent accidents, improper use of psychotropic medications without proper indication or monitoring, and failure to provide routine dental services. The facility submitted plans of correction addressing these issues.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a resident's fluids were in reach for 4 of the 6 survey days (Resident 9). | SS=D |
| Failure to ensure a resident's choice for shower times was honored (Resident 30). | SS=D |
| Failure to notify the physician of low and high blood sugars and failure to assess for hypoglycemia and hyperglycemia (Resident 1). | SS=D |
| Failure to utilize two staff for transfers, failure to use gait belts during transfers, and failure to implement fall interventions (Residents 188, 139, and 140). | SS=D |
| Failure to have indication for antipsychotic medication use, failure to implement behavioral interventions, failure to monitor antipsychotic medication, and failure to provide education on risks for 3 residents (Residents 20, 30, and 4). | SS=D |
| Failure to provide routine dental services for a resident with poor fitting dentures (Resident 12). | SS=D |
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 35
Census Bed Type - Residential: 1
Total Capacity: 36
Resident 1 blood sugar readings: 3
Resident 20 CNA behavior communication forms: 11
Resident 30 MDS assessments: 3
Resident 4 MDS assessments: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Indicated Resident 9 feeds and drinks independently but sometimes needs help | |
| Director of Nursing | Director of Nursing | Interviewed regarding blood sugar notification, fall interventions, and psychotropic medication monitoring |
| Administrator | Administrator | Provided policies and information on dental services and psychotropic medication education |
| Nurse Practitioner | Nurse Practitioner | Provided rationale for antipsychotic medication use for Residents 20, 30, and 4 |
| Activity Director | Activity Director | Interviewed about bathing/shower preference assessments |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00382936 completed on August 4, 2022.
Findings
Flatrock River Lodge was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00382936 completed on August 4, 2022; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 1
Aug 3, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00382936, which was substantiated with a federal/state deficiency cited related to the allegations.
Findings
The facility failed to ensure staff wore appropriate personal protective equipment (PPE) while conducting Covid-19 testing and failed to ensure face masks were worn properly in resident-care areas. Specific observations included an LPN not wearing a gown or N-95 mask during Covid-19 testing and a CNA wearing an N-95 mask below the nose.
Complaint Details
Complaint IN00382936 was substantiated. The deficiency related to infection prevention and control was cited at F880.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff wear appropriate PPE during Covid-19 testing and proper mask usage in resident-care areas. | SS=F |
Report Facts
Residents tested by LPN 3: 20
Census SNF/NF beds: 40
Census Residential beds: 1
Total licensed capacity: 41
Medicare census: 8
Medicaid census: 25
Other payor census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Observed not wearing proper PPE during Covid-19 testing and received an employee warning |
| CNA 4 | Certified Nursing Assistant | Observed wearing N-95 mask below nose and documented as unvaccinated with religious exemption |
| Corporate Staff 5 | Provided educational materials and policy documents related to Covid-19 PPE |
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