Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Flatonia Healthcare Center during CMS and state inspections, most recent first.
Improper Food Storage and Temperature Control: Surveyors observed raw chicken sitting on the dish sanitizing area, multiple refrigerated, frozen, and dry pantry items without required labels or discard/use-by dates, and outdated food that had not been discarded. A freezer was also found at 38 degrees with thawing food inside. The Dietary Manager, DON, ADM, and kitchen staff acknowledged that food should be dated, labeled, discarded on time, and kept at proper temperatures.
A cook prepared pureed menu items by eyeballing unmeasured amounts of milk instead of following the recipe book, including parslied noodles, pork tips, and rolls. The cook said she did not use the recipe book often and had not been trained on following recipes, while the Dietary Mgr and DON stated staff were expected to follow recipes as written. A test tray later showed the noodles had no flavor and the pork had some tough meat areas, and the facility had 3 residents on pureed diets.
Improper simultaneous feeding and lack of dignity during meals: A CNA was observed feeding two residents at the same time during lunch, without hand hygiene between residents and while handling food with bare hands. Both residents had dementia and swallowing problems, and their care plans called for supervised feeding and meal monitoring. The CNA acknowledged she had been trained to feed one resident at a time, and the DON and ADM stated the practice violated resident rights, dignity, and safe meal assistance.
Medication Administration Errors Exceeded 5% Error Rate: An LVN made two medication errors during observed med pass for a resident with dementia, dysphagia, and HTN. The LVN crushed potassium chloride ER instead of dissolving it as ordered and gave hydrochlorothiazide without first obtaining the required BP and pulse. Interviews with the CMA, LVN, and DON confirmed the errors and the missing vital sign check.
A vent in a resident room was found to be visibly dusty and had not been thoroughly cleaned for about a year. Interviews with the Maintenance Director, DON, and Housekeeping Supervisor revealed that while daily surface cleaning was performed, thorough cleaning requiring vent removal was not routinely done. Facility policies required regular cleaning and disinfection of resident-care equipment, but these were not followed for the vent.
A resident with multiple psychiatric diagnoses was not administered her prescribed Clonazepam for three days due to the facility's failure to obtain the medication from the pharmacy. Staff did not follow procedures for reordering controlled substances or notify the DON or physician about the missed doses, resulting in a lapse in medication administration.
Surveyors found multiple sanitation and maintenance deficiencies in the facility's food service areas, including a dirty water dispenser, unclean kitchen sink and drinks area, uncovered and dusty kitchen vent, and cracked tiles creating a tripping hazard. Staff interviews revealed confusion about cleaning responsibilities, and facility policies requiring regular cleaning and maintenance were not consistently followed.
Multiple incidents of physical and verbal abuse occurred when a resident with severe cognitive and behavioral issues struck two other residents, causing injury and fear, while staff failed to consistently implement or document required 1:1 monitoring. Additionally, an LPN made an inappropriate comment to a resident, further violating abuse prevention policies. Gaps in communication, documentation, and adherence to abuse protocols contributed to the deficiency.
A resident with COPD and a skin condition was not taken to scheduled pulmonary and dermatology specialist appointments as ordered by the MD. Staff interviews revealed confusion over responsibility for scheduling, lack of a clear system, and issues with finding a pulmonologist and arranging transportation. The deficiency resulted from failure to follow physician orders and facility policy for timely specialist care.
A resident in a LTC facility was subjected to misappropriation of property when a staff member, AAD-C, borrowed money for personal expenses and failed to repay it. Despite the resident's cognitive awareness and initial willingness to help, the situation led to emotional distress as AAD-C avoided the resident, causing her to feel excluded from activities. The facility's policies prohibited such actions, yet the staff member violated these rules, highlighting a deficiency in the facility's abuse prevention program.
The facility failed to ensure staff with beards wore beard restraints, as required by their policy, during food preparation and service. This oversight was observed during a kitchen tour and meal service, placing residents at risk of foodborne illness due to potential hair contamination. Interviews revealed a lack of awareness and availability of beard restraints, despite the facility's policy mandating their use.
A facility failed to adhere to its infection control policy when an LVN did not clean a resident's fingertip with alcohol before using a lancet for a blood sugar reading. The resident, who was cognitively impaired and had Diabetes Mellitus Type 2, was at risk due to this oversight. The facility's policy requires alcohol wipes to prevent infection and ensure accurate readings, but the LVN was misinformed about the necessity of this step.
Improper Food Storage, Labeling, Dating, and Freezer Temperature Control
Penalty
Summary
The facility failed to properly store raw chicken in the kitchen when a silver pan containing raw chicken was observed sitting on the dish sanitizing area during the initial kitchen tour. The Dietary Manager later acknowledged that raw chicken should not have been sitting out and stated it should have been stored at the bottom of the refrigerator. The report also documented that thawing chicken had been observed in a sink area, which the Dietary Manager stated should have been in the refrigerator. The facility also failed to properly store, label, and date multiple food items in the refrigerator, freezers, and dry food pantry. In the refrigerator, surveyors observed cooked taco meat, hamburger patties, cooked pork, salad dressings, chicken broth, honey ham, turkey breast, sliced cheese, tomatoes and lettuce for hamburgers, tator tots, and hamburger meat, many of which lacked discard dates or were not labeled. In the freezer, surveyors observed opened storage bags without labels or dates, and in the dry pantry they observed opened rolls, buns, muffin mix, corn meal, flour, instant potatoes, pancake mix, cake mixes, grits, macaroni, and corn meal containers that were opened or dated but lacked discard or use-by dates. The facility failed to discard outdated food items that remained in storage past the expected time frame. The Kitchen Aide stated staff were expected to label food with the date received, the date opened, and a discard date three days after opening. The Dietary Manager stated food items were labeled with the date received and sometimes the open date, but not always a discard date, and she acknowledged that the leftover food items shown to her should have been discarded. The DON and ADM both stated that food items should be labeled with date opened and discard dates, and that expired food should be discarded immediately. The facility also failed to ensure the first upright kitchen freezer maintained a safe storage temperature and prevented food from thawing. Surveyors observed freezer 2 at 38 degrees, with thawing sherbert, thawed Brussels sprouts, and other thawing frozen items. The Dietary Manager stated she had noticed thawing items and said a box had been blocking an area in the freezer earlier, and that staff checked temperatures in the morning, midday, and evening and recorded them on a log. The facility policy required refrigerators to be maintained at 35 F to 40 F and freezers at less than 0 F, with immediate action taken when temperatures were out of range.
Pureed Diet Recipes Not Followed During Meal Preparation
Penalty
Summary
The facility failed to prepare pureed foods according to the recipe instructions during lunch service, when a cook added unmeasured amounts of milk to country pork tips with gravy, parslied noodles, and herb butter rolls. During observation, the cook poured milk into the parslied noodles without measuring, added more unmeasured milk, and then added unmeasured milk multiple times to the pork tips and to the rolls. The cook stated she did not know how much liquid was used and said she “just eyeball[s] it,” noting that the kitchen did not have measuring cups. When the surveyor requested the recipe book, the Dietary Manager brought it over and stated it was used only for certain recipes. The recipe for parslied noodles called for only 1/8 teaspoon of liquid per 1/3 cup serving, and the recipe for country pork tips called for 0.5 ounce of liquid per 1/3 cup serving, with the meat to be pureed with broth or another appropriate sauce or gravy from the menu. The cook stated she did not use the recipe book often and had not been trained on following recipes. She also stated she had been taught to use milk to puree foods, except vegetables, and that she usually looked up recipes online or asked the manager for help. A test tray was later received for a regular texture diet, and the parslied noodles had no flavor while the pork tips had a little flavor but included a few tough meat areas. The Dietary Manager stated she was unsure whether the cooks had been properly trained in preparing diet textures and said she was still learning the facility’s processes. The DON stated the dietary department should follow recipes, and the ADM stated dietary staff were expected to follow recipes as written. Record review showed there were 3 residents on pureed diets, and the facility did not provide a pureed diet policy when requested.
Improper simultaneous feeding and lack of dignity during meals
Penalty
Summary
The facility failed to treat two residents with dignity and failed to provide individualized feeding assistance during the lunch meal. Resident #12 was a female admitted with diagnoses including unspecified dementia, major depressive disorder, and anxiety disorder; her MDS reflected a BIMS score of 00, indicating severe cognitive impairment. Her care plan identified the need for supervision with one person for feeding assistance and noted a swallowing problem related to dementia. Resident #17 was a male admitted with diagnoses including unspecified dementia, acute respiratory failure with hypoxia, metabolic encephalopathy, critical illness myopathy, dysphagia, and mood disorder; his assessment reflected severely impaired cognition, and his care plan stated he had a swallowing problem and should be monitored during meals for choking, holding food in mouth, several attempts at swallowing, and appearing concerned during meals. During observation of the dining room, CNA C was seen feeding Resident #12 and Resident #17 at the same time. At 12:26 PM, the CNA was assisting both residents simultaneously and did not wash her hands or use hand sanitizer between the two residents. At 12:40 PM, CNA C picked up Resident #17's cornbread with her bare hand, placed it on the table, then picked it back up and placed it on the plate before feeding it to him directly from her fingers. CNA D signaled that the procedure was incorrect. CNA C continued alternating between the two residents while feeding them and did not engage in communication with either resident during the meal. In interviews, CNA C stated she had been trained on abuse and neglect, resident rights, and dignity, and knew residents had the right to be treated with dignity and respect during meals. She acknowledged she had been instructed to feed one resident at a time and stated that feeding two residents at once was wrong. CNA D stated the practice was not appropriate and raised both dignity and cross-contamination concerns. The DON and ADM both stated that feeding two residents at the same time violated resident rights and dignity, could make residents feel ignored, and created safety and infection control concerns. The facility's resident rights policy stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.
Medication Administration Errors Exceeded 5% Error Rate
Penalty
Summary
The facility failed to ensure it was free of a medication error rate of 5% or greater. During observation, interview, and record review, two medication errors were identified in 26 opportunities for error, resulting in a 7.69% error rate by one LVN administering medications to one resident. The errors involved administering potassium chloride extended release in the wrong dosage form and administering hydrochlorothiazide without first obtaining the blood pressure and pulse required by the physician order. Resident #28 was a female with diagnoses including dementia, dysphagia, and hypertension. Her quarterly MDS reflected that she was rarely or never understood, had dysphagia as an active diagnosis, was dependent on staff for eating, and received speech therapy for eating or swallowing. Her physician orders included hydrochlorothiazide 25 mg daily with instructions to hold if systolic blood pressure was less than 110, diastolic blood pressure was less than 50, or heart rate was less than 60, and potassium chloride extended release 10 mEq twice daily with instructions not to crush and to dissolve in 4 to 6 ounces of water. During medication administration observation, the LVN crushed the potassium chloride and mixed it with pudding, despite the order stating not to crush it. The hydrochlorothiazide was also administered without a blood pressure or pulse being taken at the time of administration. The resident’s last documented blood pressure and pulse were from a prior date, and the progress notes reviewed did not reflect hospitalizations or episodes of low blood pressure during the review period. Interviews with the CMA, LVN, and DON confirmed that the potassium chloride should not have been crushed and that the blood pressure and pulse should have been checked and documented before giving the hydrochlorothiazide.
Failure to Maintain Clean and Safe Ventilation in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment by not ensuring that the vent in one resident room was clean and free of dust particles. During observations and interviews, it was revealed that the vent in the specified room was visibly dusty, and this issue had not been brought to the attention of the Maintenance Director. The Maintenance Director acknowledged that the vent was dusty and needed cleaning, and the DON confirmed that such dust could cause respiratory problems, indicating that vents were not being cleaned as required. The DON also stated that both Housekeeping and Maintenance were responsible for vent cleaning, and that managers should be checking vents during their rounds. The Housekeeping Supervisor reported that while daily cleaning schedules included surface dusting of vents, thorough cleaning required Maintenance to open the vent, which had not been done for about a year. The Housekeeping Supervisor was unsure if vent cleanliness impacted resident health. The Administrator was unaware of the extent of the dust in the vent and had not received complaints about vents. Review of facility policies indicated that resident-care equipment, including vents, should be cleaned and disinfected according to CDC recommendations, but these procedures were not followed for the vent in question.
Failure to Provide Timely Pharmaceutical Services for Controlled Medication
Penalty
Summary
A deficiency occurred when a resident with a history of major depressive disorder, panic disorder, generalized anxiety disorder, and bipolar disorder was not administered her prescribed Clonazepam 0.5 mg for three consecutive days. The medication was not available from the pharmacy during this period, and the facility failed to obtain it in a timely manner. The resident's medication administration record and narcotic count sheet confirmed the gap in medication availability, and interviews with staff revealed uncertainty about the process for reordering controlled substances and a lack of communication with the Director of Nursing (DON) and the resident's physician or nurse practitioner. The facility's policies required that medications, especially controlled substances, be reordered when a five-day supply remained and that the DON be notified to facilitate reordering. However, the responsible nurse did not notify the DON or the pharmacy promptly, and the DON was unaware of the medication lapse until after the fact. The nurse documented the medication as 'on order' in the resident's progress notes but did not escalate the issue or report the missed doses as a medication error, as required by facility policy. Additionally, there was no documentation of staff notifying the resident's physician or nurse practitioner about the missed doses. Interviews with staff indicated confusion regarding who was responsible for reordering narcotic medications and a lack of adherence to the facility's established procedures. The DON confirmed that she was the only authorized agent to call in narcotic medication orders but was not informed of the need. The resident reported that staff often claimed she refused her medication, and observation confirmed the medication was not available during the specified period. Facility records and interviews corroborated that the medication was not administered due to the facility's failure to obtain it from the pharmacy.
Deficient Sanitation and Maintenance in Food Service Areas
Penalty
Summary
The facility failed to maintain proper sanitation and safety standards in its food service areas, as evidenced by multiple observations of unclean and poorly maintained equipment and surfaces. Surveyors observed a water dispenser in the main dining hall with brown, slimy liquid and particles in the drip tray, a kitchen sink with brown discoloration, small brown pellets, and black mildew under the faucet, and a drinks area countertop with brown stains. Additionally, a kitchen vent was found uncovered and dusty, and cracked tiles were present under the sinks, creating a tripping hazard for staff. These conditions were directly observed during a facility inspection. Interviews with facility staff revealed confusion and lack of clarity regarding cleaning responsibilities. The Administrator stated that water dispensers were checked daily and expected to be clean, but housekeeping staff were supposed to ensure cleanliness. Dietary aides and other kitchen staff expressed uncertainty about who was responsible for cleaning specific areas, including the water dispenser and kitchen sink. The Dietary Manager indicated that a cleaning log had been implemented, but acknowledged that mold was present in the sink and that the vent had been open for an extended period. The Maintenance Director and Housekeeping Supervisor also demonstrated a lack of clear assignment for cleaning and maintenance tasks, particularly regarding the vents and water dispensers. Review of facility policies confirmed that the food service area was required to be maintained in a clean and sanitary manner, with specific responsibilities assigned to staff for cleaning and maintenance. However, the observed conditions and staff interviews indicated that these policies were not being consistently followed. The presence of unclean equipment, open vents, and broken tiles was known to several staff members and had been ongoing for some time, with no effective resolution or adherence to established cleaning and maintenance schedules.
Failure to Prevent and Respond to Resident-to-Resident and Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving aggressive resident-to-resident interactions and inappropriate staff conduct. One resident with severe cognitive impairment and a history of schizophrenia, schizoaffective disorder, and dementia exhibited repeated aggressive behaviors, including striking another resident with a pencil, causing puncture wounds and slight bleeding, and later hitting the same resident over the head with a metal object. Documentation and interviews confirmed that these incidents resulted in physical injury and fear for the affected resident, who expressed feeling unsafe and requested to press charges. Another incident involved the same aggressive resident slapping a different resident on the back, which was observed by staff and caused distress, though no physical injury was noted. Despite the known behavioral risks and documented history of aggression, the facility did not consistently implement or document 1:1 monitoring for the aggressive resident, even after multiple incidents. Staff interviews revealed confusion and lack of clarity regarding the duration and documentation of 1:1 supervision, and some staff were unaware of the full extent of the resident's aggressive behaviors. The facility's behavioral documentation system was not fully integrated into the official reporting process, leading to gaps in communication and awareness among nursing and administrative staff. Additionally, the facility's abuse prevention policy required immediate separation, assessment, and monitoring following resident-to-resident incidents, but these procedures were not reliably followed or documented. Further, a nurse was reported to have made an inappropriate and demeaning comment to a resident while pushing them in a wheelchair, stating it hurt her back and she would need a forklift to move the resident. This comment was not in line with the facility's abuse prohibition policy and contributed to a failure to ensure residents were free from mental abuse. The cumulative failures in monitoring, reporting, and staff conduct placed residents at risk for continued abuse, injury, and psychosocial harm.
Failure to Arrange and Complete Specialist Appointments per MD Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with physician orders, the comprehensive care plan, and the resident's preferences. Specifically, the resident was not taken to her MD-referred pulmonary and dermatology appointments, despite orders dated 02/24/25 for referrals due to COPD and a rash. Interviews with the resident confirmed she had not attended either specialist appointment. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for scheduling and ensuring follow-through on specialist appointments. The DON acknowledged that the orders were not carried out and that there was no established system or designated person responsible for scheduling such appointments. Further interviews indicated that the failure to arrange the pulmonary appointment was due to an inability to find a pulmonologist and transportation issues. Staff, including the LPN, LVN, ADON, and Administrator, all recognized the importance of following through with MD orders for specialist care and acknowledged that the process had failed. The facility's policy required that orders for medications and treatments be consistent with safe and effective practices, but this was not followed in this instance.
Misappropriation of Resident's Money by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property by allowing a staff member, AAD-C, to borrow money from the resident for personal expenses. The resident, who was cognitively intact with a BIMS score of 15, had loaned money to AAD-C on three separate occasions, totaling $33. The resident initially offered the money to AAD-C, who was in financial distress, but expected repayment. However, AAD-C did not repay the money and began avoiding the resident, leading to the resident feeling excluded from activities and emotionally distressed. The resident reported the situation to the Director of Nursing (DON) and the Administrator after being found crying in her room. The resident expressed that the emotional impact of being avoided and excluded from activities was more distressing than the financial loss itself. The DON confirmed that AAD-C admitted to borrowing money and avoiding the resident due to the debt. The facility's grievance report documented the resident's account of the events and the emotional impact it had on her. The facility's policies clearly prohibited staff from accepting gifts or borrowing money from residents, as outlined in the Employee Handbook and the Abuse Prohibition Policy. Despite these policies, AAD-C, who had previously conducted meetings to inform residents about not giving money to staff, violated these rules. The incident highlighted a failure in the facility's abuse prevention program, which includes components such as screening, training, prevention, and protection.
Failure to Use Beard Restraints in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation, as observed during a kitchen tour and meal service. Two staff members, identified as having beards, were not wearing beard restraints, which is a requirement to prevent hair from contaminating food. The Dietary Manager was unavailable due to sick leave, and one of the staff members was unaware of the availability of beard restraints in the kitchen. This oversight placed residents at risk of foodborne illness due to potential hair contamination. Interviews with staff revealed a lack of awareness and availability of beard restraints, despite the facility's policy requiring them. The interim Dietary Manager confirmed that an in-service on hair and beard restraints was conducted, emphasizing the necessity of these measures to prevent foodborne illness. The facility's policy, reviewed in June 2024, mandates that all employees handling food must be trained in safe food handling practices, including the use of hair nets or beard restraints to prevent contamination.
Infection Control Lapse During Insulin Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during insulin administration to a resident. LVN A did not clean the resident's fingertip with an alcohol prep pad before using a lancet to obtain a blood sugar reading. This action was contrary to the facility's policy, which requires staff to wipe the area with alcohol before lancing. The resident involved was a cognitively impaired elderly female with a diagnosis of Diabetes Mellitus Type 2, who was receiving diabetes medication as per her care plan. During an interview, LVN A mentioned that she had previously been informed by state employees that using alcohol before lancing was not required, although she was originally taught to do so. The Director of Nursing confirmed that the facility's policy mandates the use of alcohol wipes before lancing to prevent infection and ensure accurate blood glucose readings. The failure to adhere to this policy could potentially place residents at risk of infection and inaccurate blood sugar readings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Flatonia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shady Oak Nursing And Rehabilitation | 8.7 mi | ★★★★★ | 10 | 0 |
| Paradigm At The Oak | 11.7 mi | ★★★★★ | 30 | 3 |
| Schulenburg Regency Nursing Center | 12.4 mi | ★★★★★ | 8 | 0 |
| Shiner Nursing And Rehabilitation Center Inc | 18.3 mi | ★★★★★ | 13 | 0 |
| Monument Rehabilitation And Nursing Center | 19.3 mi | ★★★★★ | 8 | 0 |
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