Health inspection·December 4, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure the cleanliness of kitchen equipment, per manufacturer's instructions, for 1 of 1 ice machines reviewed for food safety requirements. Residents Affected - Many The facility failed to ensure the ice machine was descaled and failed to ensure a plastic bin that held an ice scooper was free from scale buildup. This failure placed all residents at risk for illnesses related to prolonged exposure to scale. Findings include: Review of AM AIDE DAILY CLEANING LIST, undated, reflected a weekly schedule of EQUIPMENT TO BE CLEANED. A B was observed to be initialed next to the task WIPE DOWN ICE MACHINE IN HALLWAY. No date was observed on the sheet to indicate which week the task had been completed. Observation of the ice machine on 12/4/23 at 10:47 AM revealed white-colored streak marks on the left side, right side, and in the crevice of the door of the machine. A plastic, blue container was observed attached to the left side of the ice machine, and appeared to be coated with the same, white-colored substance. Inside the plastic, blue container, a silver ice scooper was observed. At the bottom of the container, the same white substance was observed. During an interview and observation on 12/4/23 at 11:53 AM, the DFS identified the white-colored substance to be lime and the streaks to have been caused by hard-water. The DFS stated a part of staff's weekly cleaning schedule includes cleaning the ice machine, which includes de-liming the machine. She stated the machine was rented, and the facility's responsibility was to maintain the outside of it. She stated initials on the AM AIDE DAILY CLEANING LIST indicated the task was completed. During an interview on 12/4/23 at 1:36 PM, the DFS reiterated that the facility had lime build-up from hard water. She stated staff should have been cleaning the ice machine daily, but they were not educated to do so. She stated she reached out to the company from whom they rent the ice machine from for service and planned to in-service staff on cleaning the ice machine and the container that holds the ice scooper using the de-scaling products that were available at the facility. She stated she also planned to update the AM AIDE DAILY CLEANING LIST to include cleaning the container that holds the ice scooper. The DFS added that facility policy stated to clean the ice machine according to manufacturers instructed; she provided the policy and manufacturer's instructions. She stated she was responsible for ensuring completion of the cleaning tasks and stated that the lime had the potential to negatively affect residents if ingested but did not identify specific risks. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675140 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 675140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Hamilton 1315 East State Hwy 22 Hamilton, TX 76531 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)