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F0921
D

Failure to Maintain Clean and Sanitary Environment in Dining, Hallways, and Kitchen

Huntsville, Texas Survey Completed on 11-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment in several key areas, including one of two dining rooms, all six resident halls, and the kitchen. Observations revealed that the exterior windows throughout the building, including those in the dining room and resident rooms, were covered with a mixed dark and light green substance on the outside, behind the screens, obstructing the view and indicating a lack of regular cleaning. Staff interviews confirmed that the windows had not been cleaned on the outside, and housekeeping staff were not assigned or instructed to clean them. Some staff and residents noticed the dirty windows only when prompted, and no complaints had been made prior to the survey. In the kitchen, significant cleanliness issues were observed, including sticky, thick brown and black substances with accumulated dirt and debris along the floor edges, black buildup and cracks between tiles under the prep table, a white crusty buildup under the prep table, and a brown sticky buildup with dirt and debris in the metal drip pan under the hot water heater. The lower storage shelves also had a thick brown, sticky accumulation of dirt and debris. Review of cleaning logs for the previous three months showed that staff had not completed or signed off on assigned cleaning tasks, and interviews with dietary staff revealed that deep cleaning of baseboards, under equipment, and shelves was not routinely performed. Staff cited lack of time and unclear assignment of deep cleaning duties as reasons for these lapses. Facility policies reviewed required regular cleaning and disinfection of environmental surfaces, including floors and kitchen areas, and assigned responsibility for these tasks to specific staff roles. However, interviews with the DON, dietary manager, and housekeeping staff indicated a lack of oversight and follow-through on these policies. The DON was unaware of the need for deep cleaning in the kitchen, and the administrator had not noticed the extent of the window debris until it was pointed out. Residents interviewed generally did not complain about the cleanliness of their rooms or the dining area, but acknowledged the windows were dirty when asked. The failure to maintain cleanliness and sanitation in these areas was directly observed and confirmed through staff interviews and record review.

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