Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 0 |
| Paradigm At The Oak | 11.7 mi | — | 12 | 3 |
| Schulenburg Regency Nursing Center | 12.4 mi | — | 1 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.