Health inspection·November 19, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few windows needed to be cleaned. She took a napkin, wiped the inside of the window, and said the debris was on the outside of the window. She said the debris could be mold or pollen buildup. She said the residents did not have a clear view out of the windows. During an observation on 10/20/2025 at 9:40a.m., the residents' windows on halls 100-600 were externally covered with a mixed dark and light green substance that covered the entire window (the green substance was on the outside of the windows and behind the screen).During an interview on 10/20/2025 at 1:20 p.m., CNA E said she noticed the windows needed to be cleaned on the outside. She said she wiped down the window seals and windows on the inside of some of the residents' rooms. She said the residents had not complained about the cleanliness of their rooms or windows. She said she had not reported the dirty windows to the administrator, nor had she seen the housekeeping staff or anyone cleaning the windows on the outside.During an interview on 10/20/2025 at 1:28 p.m., with Resident #1 she said she liked the food and had no issues with the facility. She said the dining room was always clean. When Resident #1 was asked about the windows in the dining room and in her room, she said the windows could be cleaned but she never complained, and it could be worse, so she did not say anything.During an interview on 10/20/2025 at 1:34 p.m., MA F said she had not noticed the windows being dirty because they are always covered. She said she had not noticed anyone cleaning the windows. When asked to look at the windows MA F said, oh my they are really bad , and she never noticed the green build-up on the windows in the past. She said the windows needed to be cleaned. She said the residents would have a clear view outside and would enjoy looking outside more.During an interview on 10/20/2025 at 1:40 p.m., with Resident #2 said she was doing fine. When asked about the windows in her room and in the dining room she said she never really noticed anything but now that she had been asked, she saw they were dirty and needed to be cleaned. She said she did not look out the windows in the dining room because there was always a curtain or blind over them.During an interview on 10/20/2025 at 2:20 p.m., DA-D said he never cleaned the baseboards or the shelves in the kitchen. He said they were assigned duties in the kitchen and were expected to keep the kitchen area clean and free of dirt and debris. He said the kitchen was small and should be easy to clean. He said uncleanliness in the kitchen could make the residents sick if food accidentally got contaminated.During an interview on 10/20/2025 at 2:33 p.m., DA-C said she wiped down the kitchen shelves but had not deep cleaned them. She said she swept and mopped the kitchen floors but had not deep cleaned the baseboards or under appliances in the kitchen. She said there were some areas that really could use bleaching and scrubbing but by the time her shift was over there was no extra time. She said she felt the DM and Administrator should ask 2 or 3 staff to come in after meal service hours once per month and deep clean the kitchen from top to bottom. She said she tried to keep her area clean as she understood food could become contaminated and make the residents sick in some way.During an interview on 10/20/2025 at 2:40 p.m., Houskeeper-A said he has never been asked to clean the windows inside or outside. He said he saw the green substance on the windows. He said he never reported the dirty windows to anyone or asked about cleaning them. He said the windows needed to be cleaned and he is willing to assist in cleaning the windows in the future. He said he now saw the residents did not have a clear view when sitting in the dining room or in their rooms and that was not fair to the residents or their visitors.During an interview on 10/20/2025 at 2:54 p.m., Housekeeper-B said he was assigned to different halls daily. He said he cleaned the residents' rooms and assured the residents' space, and the dining room floors were clean. He said he never washed the windows of the facility and had never been asked to wash them. He said he thought the housekeeping supervisor was responsible for the outside cleaning and window maintenance. He said he never noticed the windows and had cleaned the window ledges in the past. He said the residents or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675433 If continuation sheet Page 2 of 3 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 675433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Huntsville 1302 Nottingham St Huntsville, TX 77340 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete family members never complained about the dirty windows.During an interview on 10/20/2025 at 3:40 p.m., the Administrator said she noticed the windows needed cleaning on the outside. She said she would get the windows pressured washed and cleaned. She said there were curtains or blinds over every window that made the stains on the window less noticeable and, staff as well as residents, go on with their day and not notice the stains. She said she did not believe the stain was molded and could possibly be pollen. She said she would in-service all staff on environmental cleaning in all areas of the facility. She said she did not know the baseboards, floor or shelves needed a deep cleaning. She said the kitchen staff had a log that was used to assign tasks, and staff were to sign that tasks were completed daily. She said she did not realize the cleaning logs were not being utilized and signed on a daily basis. She said she would check daily to assure the kitchen staff were assigned cleaning tasks as well as signing the cleaning logs that they completed the task. She said she went into the kitchen about an hour earlier in the day on (10/20/2025) and helped scrub the floors and baseboards in the kitchen. She said the building was old and some of the stains would not come off but there were some that needed to be removed. She said staff and residents could become ill from improper cleaning, infection control and food borne illnesses. She said her goal was to ensure better and more frequent environmental checks and cleanliness of the building.Record review of an In-Service Training report titled Cleaning of the kitchen, dated 9/23/2025, indicated, All employees must ensure at all times floors are kept clean and mopped. Each employee must perform 2 cleaning tasks per shift. All equipment [NAME] be wiped down, tables pulled out and mopped and swept behind, No exceptions.Record review of a facility policy titled Cleaning and Disinfecting Residents' rooms, dated August 2013, read .2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.Record review of a facility policy titled Floors revised, dated December 2009, read, .Policy Statement: Floors shall be maintained in a clean, safe, and sanitary manner. Policy Interpretation and Implementation revealed, 1. All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures. 2. Floor cleaning procedures are maintained by the Environmental Services Director. Record review of a facility policy titled Infection Control dated 10/25/2022, read, . Policy: This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.2. c. Maintain a safe, sanitary and comfortable environment for personnel, resident, visitors, and the public. Record review of a facility policy titled Sanitation, dated November 2023, read, .Policy, Food & Nutrition Services Personnel will be responsible to maintaining the cleanliness and sanitation of kitchen. Procedure: 1. The Director of Food & Nutrition Services is responsible for utilizing the kitchen cleaning schedule template and assigning task to staff on a daily, monthly and annual basis (refer to example template).Record review of a facility policy titled Resident Rights, dated November 2021, read, .Dignity and Respect: you have the right to: *Live in safe, decent and clean conditions.Record review of a facility policy titled Abuse dated 9/28/23 read .Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. Event ID: Facility ID: 675433 If continuation sheet Page 3 of 3