Flatonia Healthcare Center

Inspectors wroteBased 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 The facility failed to discard outdated food items located in the refrigerator on 12/02/2025,12/03/2025, and 12/04/2025. 4.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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents were free from physical abuse for two (Resident #2 and Resident #3) of six residents reviewed for abuse. 1. The facility failed to ensure Resident #2 was not attacked by Resident #1 with a pencil on 08/11/25 causing slight bleeding and the facility failed to ensure Resident #2 was not hit over the head by Resident #1 with a metal object on 08/15/25, no physical injury, causing Resident #2 to be afraid of Resident #1.2. The facility failed to ensure Resident #1 did not slap Resident #3 on the back on 08/20/25.3. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record review the resident's right to be free from misappropriation for 1 of 3 residents reviewed for misappropriation of property. (Resident #1) The facility failed to protect Resident #1 from misappropriation/exploitation by allowing AAD-C C to take money from Resident #1 for AAD-C's own well-being and personal expenses, exact date unknown. Resident #1 felt excluded from activities and became upset after AAD-C began avoiding the resident who was asking for her money to be paid back. This failure could place residents who resided in this facility at risk of misappropriation of property causing financial hardship.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.