Flatrock River Lodge

In the surveyor’s words

From the most serious findings on record at Flatrock River Lodge, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 8, 2024

  Based on interview and observations, the facility failed to date open and/or prepare food products in the walk-in refrigerator. This deficient practices had the potential to aversively affect 34 of 34 residents who receive foods from the dietary department. Findings include: During an observation on 3/4/2024 at 6:50 p.m., three small bowls of prepared cottage cheese, a small bowl of prepared tomatoes, a plastic container of what Dietary Aide 2 identified as barbequed beef, a pitcher of orange liquid, and a cart with multiple glasses prepared with various drinks were all noted to not to be dated of when it was opened/prepared or with a use-by date. […]

• No harm, potential for more than minimal, widespreadF880Aug 4, 2022

  Based on observation, interview and record review, the facility failed to ensure staff wear the appropriate personal protective equipment (PPE) while conducting Covid-19 testing for residents and staff ensure face masks are worn to cover the nose and mouth when in resident-care areas. (LPN 3 and CNA 4) Findings include: 1. During a tour of the facility on 8-3-22 at 11:12 a.m., an observation was conducted of LPN 3 preparing to conduct Covid-19 testing with Resident G. Resident G was located in the 200 hallway when LPN 3 was observed explaining to her she needed to see her for testing. LPN 3 was observed assisting Resident G by wheeling her to the Covid-19 testing supply cart, located in the hallway, outside of room [ROOM NUMBER]. […]

• No harm, potential for more than minimal, isolatedF550Apr 10, 2026

  Based on interview, observation, and record review, the facility failed to ensure a resident was treated with dignity by timely assisting with care for 1 of 4 residents reviewed for dignity. (Resident 22)Findings include:The clinical record for Resident 22 was reviewed on 04/09/2026 1:42 PM. The medical diagnoses included, but were not limited to, chronic respiratory issues (the lungs cannot adequately exchange oxygen and carbon dioxide) and muscle wasting. A Quarterly Minimum Data Set Assessment, dated 1/9/2026, indicated Resident 22 was cognitively intact. The resident needed substantial to maximal assistance with personal hygiene, dressing, and toilet hygiene. The resident needed partial to moderate assistance with sitting to standing transferring, toilet transferring, and walking. […]

• No harm, potential for more than minimal, isolatedF585Apr 10, 2026

  Based on interview and record review, the facility failed to file grievances on behalf of a resident voicing concerns with staff for 1 of 3 residents reviewed for grievances.Findings include:The clinical record for Resident 1 was reviewed on 04/09/2026 1:57 PM. The medical diagnoses included, but were not limited to, a lung infection known as diabetes (chronic high blood sugar levels), and heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's requirements). […]

• No harm, potential for more than minimal, isolatedF676Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to assist a resident with eating who required cuing for 1 of 2 residents reviewed for Activities of Daily Living. (Resident 15) Findings include:The clinical record for Resident 15 was reviewed on 4/8/26 at 9:26 a.m. The diagnoses included, but were not limited to, bilateral chronic angle-closure glaucoma (eye condition where the iris progressively blocks both eye's drainage angle, causing high eye pressure and irreversible optic nerve damage) severe stage, abnormal involuntary movements, dementia (mental decline), muscle weakness, and lack of coordination (needing assistance with personal care). […]