Focused Care At Huntsville

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.

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