Inspection·October 5, 2024

F 0602 Level of Harm - Actual harm Residents Affected - Few [AAD-C] to be able to get something to eat because she couldn't afford to eat. She [Resident #1] stated the 2nd time was after she [AAD-C] wrecked her car, she [Resident #1] again loaned her $10 for 'something to eat. [Resident #1] stated the 3rd time she [AAD-C] asked [Resident #1] gave her the last of her money at the time and it was $13. [Resident #1] is adamite [sic] that [AAD-C] had borrowed $33 and had not paid her any of the money back. [Resident #1] states that [AAD-C] has been avoiding her. [Resident #1] states she hasn't been invited to activities in a long time. When asked how long she stated a couple months. Record review of a form titled Disciplinary Action Record, dated 8/15/24, revealed the form was a notice of suspension for AAD-C who wrote her statement that read [Resident #1] gave me $20 dollars for gas (offered) I refused at first and then she said, everyone needs help and gave me the $20. I have given the $20 back as soon as I got paid and haven't heard any complaints until today. Attempts to interview AAD-C were unsuccessful, three attempts were made to reach her by telephone on 9/5/24 at 10:47 am, 11:45am, and 3:39 PM. The number goes to the phone voicemail automatically which then states the voicemail has not been set up. There was no opportunity to leave a message. No return call was received. In an interview on 9/5/24 at 9:56 am with Resident #1 revealed she did not remember the dates, about 3 months ago or more, but she had thought she was just letting AAD-C borrow money to eat. AAD-C did not ask for the money the first time. Resident #1 stated she offered because she did not want AAD-C to go without eating. Resident #1 stated she cared about the staff. AAD-C had told her she would pay her back. Resident #1 stated she gave AAD-C eight dollars, she's not certain now of the amount. The second time was ten dollars. AAD-C came to her room and told her that she had an accident in her car and had no money again and would not be able to eat. Resident #1 stated we talked about this just being a loan and that I did not have much money. The third time AAD-C came into my room and asked if she could borrow ten dollars again. She had told me she would catch up with me when she got her next paycheck. Resident #1 stated she gave her ten more dollars. Resident #1 explained to AAD-C that was the last of her money. Resident #1 stated after she paid for her care at the facility, she only got a small amount of money each month. Resident #1 stated she used her limited money to order food to be delivered a few times a month. Resident #1 stated she had not realized that when she started asking AAD-C for the money back that she would no longer be invited to activities and that AAD-C would start avoiding her. Resident #1 stated it did hurt her feelings because she had thought they were friends. Resident #1 stated on the day she was crying she had heard AAD-C asking MA B to come into her (Resident #1's) room so that she did not have to see Resident #1. Resident #1 stated by then it had been a couple of months since she had attended an activity, which did bother her. Resident #1 stated that once the DON and ADM found out about the money, they made sure she got the money back and AAD-C was no longer working there. Resident #1 stated she now knew that residents were not to ever give any staff any money. Resident #1 stated it was not really the money loss that bothered her as much as how she was treated. Resident #1 stated she no longer trusted people. In an interview on 9/5/24 at 2:55pm with MA B revealed that she had been told by Resident #1 previously about AAD-C borrowing money, but she had assumed it was that AAD-C had just forgotten to give her the change when she had bought something for her. MA B stated she assumed it had been taken care of the next time she worked. On 8/15/24 they had a scheduled visit with the Psychiatrist that day. AAD-C usually carried around a tablet so the Psychiatrist could talk to the residents via facetime. MA B stated on that day AAD-C asked her to take the tablet in Resident #1's room for her because she did not want to see the resident. MA B stated she had never heard AAD-C say that before, but she had refused because she was doing something else. MA B stated that a minute later Resident #1 called MA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Actual harm Residents Affected - Few B to her room and told her that AAD-C did not want to see her because she owed her money. MA B stated she did end up helping with the tablet and planned to go tell the DON who was the person in charge that day. MA B stated before she made it to the DON, the DON found Resident #1 crying in her room. MA B stated that AAD-C and Resident #1 had been close and were frequently together when AAD-C worked. MA B stated she could tell that Resident #1 had been hurt that AAD-C treated her that way. She stated Resident #1 stayed in her room more and rarely came out for quite a while. In an interview on 9/5/24 at 2:05pm with the facility DON revealed on 8/15/24 she was getting ready to leave for the day, so she had been doing a final round of the facility which she does daily and found Resident #1 in her room crying. The DON stated Resident #1 told her about AAD-C borrowing money from her and that AAD-C was avoiding her and not inviting her to activities. Resident #1 also told her about hearing AAD-C asking MA B to go help Resident #1, so she did not have to see her. The DON stated she went to talk to AAD- C who did not deny that she had borrowed money from Resident #1. She admitted she had been avoiding the resident because Resident #1 was asking her when she was going to pay the money back. AAD-C claimed that she had paid Resident #1 back some of the money. The DON stated AAD-C knew she should not take money from a resident. She (AAD-C) had been the one to do a resident counsel meeting with the residents last year when a housekeeper had kept the change from Resident #1's request for items from the store, and the housekeeper was fired. The DON stated she had AAD-C fill out a statement then sent AAD-C home and walked her out to her car to leave. AAD-C has not answered calls since then. The DON stated Resident #1 has just recently started attending activities again and leaving her room more frequently. In an interview on 9/5/2024 at 2:45pm with the facility Administrator revealed she found out about the allegation from the call from the DON. She stated she does rounds every morning and Resident #1 had never mentioned a concern with staff or having loaned money. The Administrator stated all staff were required to sign the Employee handbook after reading. The Handbook contained information on misappropriation and that they were not allowed to accept gifts or money from residents. She stated they also had an incident last year when a housekeeper kept Resident #1's change after a trip to the store to buy items for her. AAD-C did meetings with the residents to make sure they were aware not to loan or give money or gifts. The Administrator stated per the facility policy the AAD-C's employment was terminated. They interviewed every other resident and did not find anyone else that AAD-C or anyone else that had given money to staff. She stated she expected the staff to follow the policy and code of conduct that they agreed to when hired . Review of the facility Employee Handbook, dated, 8/14/2017, included the following: Acceptance of Gifts, Tips, and Fees Acceptance of any gifts, tips, fees, or other form of remuneration from resident, family members, clients, suppliers, lenders, landlords, etc. is not permitted unless disclosed and approved by the Facility Administrator. Under no circumstances are associates allowed to borrow or ask to borrow, from residents or resident family members. This includes money, personal items, etc. Solicitation of tips or gratuities of any kind is strictly prohibited. Review of the facility policy titled Abuse Prohibition Policy, revised 1/1/24, reflected the following: Misappropriation of property/financial abuse/Exploitation is defined as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Involuntary Seclusion is defined as separation of a resident from other residents or from Level of Harm - Actual harm her/his room or confinement to her/his room (with or without roommates) against the Residents Affected - Few resident's will, or the will of the resident representative. Abuse Prohibition Program: The facility's abuse prevention program includes the following components: ? Screening ? Training ? Prevention ? Identification ? Investigation ? Protection ? Reporting/ Response FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 4 of 4