Flatonia Healthcare Center

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly store raw chicken in its kitchen on 12/02/2025.2. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 12/02/2025, 12/03/2025 and 12/04/2025. 3. The facility failed to discard outdated food items located in the refrigerator on 12/02/2025,12/03/2025, and 12/04/2025. 4. The facility failed to ensure the first upright kitchen freezer maintained a safe storage temperature and did not allow food items to thaw.These failures could place residents who received meals from the kitchen at risk of foodborne illnesses. Observation during the initial tour of the kitchen on 12/02/2025 beginning at 8:54 AM revealed the following:1 silver pan containing raw chicken sitting on dish sanitizing area.Refrigerator:1 pan of cooked ground taco meat dated 11/28/2025, no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 kitchen reviewed for food and nutrition services.The facility failed to ensure [NAME] A refrained from adding an unmeasured amount of liquid to country pork tips with gravy, parslied noodles, and herb butter roll pureed meals during lunch service on 12/03/2025.This failure could place residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss.Observation and interview on 12/03/2025, at 11:09 AM, revealed [NAME] A poured an unmeasured amount of milk into the parslied noodles without measuring after mixing one time, [NAME] A added another unmeasured amount of milk. [NAME] A was then observed preparing 3 herb butter rolls, adding an unmeasured amount of milk. Followed by [NAME] A adding an unmeasured amount of milk 3 different times to 3 large spoons of country pork tips. The mixture did not resemble the color of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to treat each resident with respect and dignity and failed to provide care for each resident in a manner and environment that promoted the maintenance or enhancement of quality of life for 2 (Resident #12, Resident #17) of 10 residents reviewed for dignity.The facility failed to ensure that Resident #12 and Resident # 17 were provided dignified and individualized feeding assistance during the lunch meal on 12/02/2025.This failure could place residents at risk of diminished dignity and negatively affect their quality of life. Record review of Resident #12 Face sheet dated 12/03/2025, reflected she was a [AGE] year-old female, who was admitted to facility on 03/08/2025 with diagnoses of unspecified dementia (memory loss), major depressive disorder unspecified (feel sad, hopeless), and anxiety disorder. Record review of Resident # 12's MDS assessment, dated 10/31/2025, reflected she had a Brief Interview for Mental Status (BIMS) score of 00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of 5% or greater. There were two (2) medication errors in 26 opportunities for an error rate of 7.69% by 1 of 3 staff members observed (LVN) administering medications to 1 of 7 residents. (Resident #28). LVN attempted to administer Resident #28 Potassium Chloride Extended Release Oral Capsule Extended Release 10 milliequivalents, crushed with pudding. Order stated, Potassium Chloride ER Oral Capsule Extended Release 10 MEQ (Potassium Chloride) Give 1 capsule by mouth two times a day for supplement do not crush, may dissolve in 4-6oz (ounces) of water. Medication was attempted to be administered in the incorrect dosage form. LVN administered hydroCHLOROthiazide Oral Tablet 25 MG (milligrams). The order stated, hydroCHLOROthiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF SBP (systolic blood pressure) IS <…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff and public for one (room # 411 vent) of seven vents observed and reviewed for environment. The facility failed to ensure the vent in room [ROOM NUMBER] was clean and free of dust particles. These deficient practices placed residents at risk for illness and decreased quality of life.Findings included:During an interview on 10/13/2025 at 2:03 pm the Maintenance Director stated the vent/AC register was responsible for directing the air. The Maintenance Director looked at the picture of the vent from room [ROOM NUMBER], and he stated that it was probably dust and needed to be cleaned. The Maintenance Director stated he would think it would have an impact on the residents, dust in their room, but was not sure of medical issues. The Maintenance Director said the dust in the vent of room [ROOM NUMBER] was not brought to his attention.During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of each resident for one resident (Resident #1) of four residents reviewed for medication administration in that: Resident #1 was not administered her Clonazepam 0.5 MG (anti-anxiety medication-- is a benzodiazepine medication used to treat panic disorders, certain seizure disorders, and movement disorders) for 3 days from 09/23/2025 to 09/25/2025 due to the facility not obtaining medication from the pharmacy. This failure could place residents on anti-anxiety medication at risk for increased anxiety and depression and change in ADLs.Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted on [DATE] with the following dx. Major Depressive Disorder, recurrent, moderate (a mood disorder that causes a persistent feeling of sadness and loss on interest),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. for 1 of 1 kitchen observed in that:The facility failed to ensure the water dispenser in the main dining hall was clean.The facility failed to ensure the sinks in the kitchen were clean.The facility failed to ensure the Resident's drink area in the kitchen was clean.The facility failed to ensure the vent in the kitchen was closed and clean.The facility failed to ensure there were no broken tiles in the kitchen.These deficient practices placed residents at risk for illness and decreased quality of life.Findings included:Observation on 10/13/2025 at 10:02 am reflected the water dispenser/drinking fountain in the main dining area had brown-colored liquid in the drip tray that looked slimy with tiny particles. Observation on 10/13/2025 at 10:05 am the kitchen sink was brown-colored and there were two small brown pellets on the drain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of five residents (Resident #4) reviewed for quality of care.The facility failed to ensure that Resident #4 was taken to her MD referred pulmonary and dermatology appointments referral date 02/24/25.These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life.Findings included:Record review of Resident #4's MD orders dated 02/24/25 reflected, refer to pulmonology DX COPD and refer to dermatology for rash.Interview on 09/01/25 at 4:26 pm with Resident #4 reflected she had not been taken to her specialist appointments of either the dermatologist or the pulmonologist.Interview on 09/02/25 at 5:29 pm with the LPN A reflected it was the responsibility of the charge nurse to follow up on scheduling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for two of two staff reviewed for food safety and sanitation. The facility failed to ensure two staff, [NAME] B and [NAME] C wore beard restraints . This failure placed residents at risk of foodborne illness. Findings included: Observation on 07/30/2024 at 9:20 AM during the initial kitchen tour, [NAME] B had a beard and was not wearing a beard restraint. Observation and interview on 07/30/2024 at 12:05 PM during meal service in the kitchen, [NAME] B and [NAME] C had beards and were not wearing beard restraints. [NAME] B stated the Dietary Manager was on sick leave and was not available for an interview. He stated he was not aware of any beard restraints in the kitchen for staff to wear. In an interview on 07/31/2024 at 10:00 AM the ADM stated the men in the kitchen did not have beards until this month. She stated the kitchen did not have beard covers until it was brought to her attention. She stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for one of one staff observed for insulin administration (LVN A ). LVN A failed to clean Resident #16's fingertips with alcohol prep pad before puncturing the fingertip with a lancet for a blood sugar reading. This failure could place residents at increased risk of infection and inaccurate blood sugar readings. Findings included: Review of Resident #16's Face Sheet reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus Type 2. Review of Resident #16's quarterly MDS dated [DATE] reflected a BIMS score of 04 which indicated she was severely impaired cognitively. Review of Resident #16's Care Plan (no date) reflected; Resident #16 had Diabetes Mellitus and she was to receive the diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 of 5 residents reviewed for environment. The sink in Resident #1's room did not produce hot water. This failure placed residents at risk of discomfort and poor hygiene. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia with hemiparesis, sequelae of cerebral infarction (pathological conditions resulting from stroke), morbid obesity due to excess calories, cognitive communication deficit (difficulty communicating due to impaired cognition), muscle spasm, insomnia, polyneuropathy (damage to peripheral nerves), chronic idiopathic constipation (constipation with no known cause), anxiety disorder, major depressive disorder, attention deficit hyperactivity disorder, chronic pain, rheumatoid arthritis, pain in right shoulder, abnormalities of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had the right to organize and participate in resident groups in the facility for seven of seven anonymous residents reviewed for resident council. The facility failed to facilitate resident council meetings regularly and as scheduled per their resident council policy. This failure placed residents at risk of not having the right to participate in resident groups. Findings included: A record review of Resident #14's face sheet dated 6/14/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (movement disorder), atrial fibrillation (irregular heartbeat), bipolar disorder (extreme mood swings), major depressive disorder (depression), and muscle weakness. A record review of Resident #14's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. A record review of Resident #14's care plan last revised on 4/17/2023 reflected she had little or no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment for one of seven anonymous residents reviewed for homelike environment. The facility failed to ensure the shower room on the 300 hall was free of a black substance. This failure placed residents at risk of having an unclean environment. Findings included: During a confidential meeting on with residents on 6/13/2023, a resident reported the shower room on the 300-hall had mold. During an observation and interview on 6/13/2023 beginning 3:30 p.m., the shower room on the 300-hall appeared to have a black cloudy-looking substance in the cracks and corners of the floor where the floor met the wall on the right side of the shower room. CNA C stated he had not encountered mold before and did not know what the black substance was in the shower room but he did not think it was mold because he thought that would smell bad and there was no odor. CNA C stated housekeeping was supposed to clean the shower room every day but he was not sure whether…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.