Health inspection·July 12, 2023

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meals (lunch meal) reviewed for menus and nutritional adequacy. Residents Affected - Some Dietary staff did not serve bread during the noon meal on 07/10/23 to any residents eating food provided by the dietary department. This failure could place residents who eat food from the kitchen at risk of not having their nutritional needs met. Findings included: The planned menu dated 07/10/23 for the noon meal was herb roasted chicken, creamy noodles, garlic green beans,1 slice of bread, and banana pudding for dessert. The diet spreadsheet for the noon meal indicated residents were to receive Herb Roasted Chicken 3 oz., Creamy Noodles 4 oz., Garlic [NAME] Beans 4 oz., Banana Pudding, #8 dip (3.75 oz. or 1/2 cup), 1 slice Bread/Margarine 1 tsp. Residents on pureed diets were to receive Pureed Herb Roasted Chicken #8 dip (3.75 oz. or 1/2 cup; Pureed Creamy Noodles #12 dip (2.875 oz. or 1/3 cup); Pureed Garlic [NAME] Beans #12 dip (2.875 oz. or 1/3 cup); ; Pureed Banana Pudding #8 dip (3.75 oz. or 1/2 cup); Pureed Bread # 20 dip (1.875 oz. or 3.5 tablespoons) During an observation of the dietary department on 07/10/22 at 11:45 AM the dietary carts contained trays for each resident receiving food from the kitchen. Each tray had silverware/napkin, dietary slip, banana pudding, a single serving container of margarine, and a beverage of the resident's choice. There was no sliced bread or pureed bread on the trays. During an observation on 07/10/23 at 12:28 PM, tray line service began and continued until 01:04 PM and the following was observed: *At 12:40 PM the dining room cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 12:53 PM the hall 100 cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 01:02 PM the hall 200 cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 01:04 PM the hall300/400 cart left the kitchen and no sliced bread were placed on any trays. There were no residents on these halls receiving a pureed diet. During an interview on 07/10/23 at 01:07 PM [NAME] A said he was responsible for preparing the pureed bread and he did not prepare any. During an interview on 07/10/23 at 01:08 PM, the DM said the cook was responsible to put the bread on the trays whether it was sliced bread, rolls, cornbread, or pureed breads. She said she expects (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675898 If continuation sheet Page 2 of 5 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 675898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Lake Nursing Home 1611 W Royall Blvd Malakoff, TX 75148 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 0803 bread to be served to residents if it was part of the menu or if a resident requested bread. Level of Harm - Minimal harm or potential for actual harm Review of a facility Diet Roster dated 07/10/2023 indicated there were 50 residents receiving food from the kitchen. Residents Affected - Some Review of a facility menu policy dated 10/2017 indicated Menus are developed ad prepared to meet established national guidelines for nutritional adequacy. And .1. Menus meet the nutritional needs of the residents in accordance with the recommended dietary allowances . and .9. If a food group is missing from a resident's diet, the resident is provided an alternate means of meeting his or her nutritional needs FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675898 If continuation sheet Page 3 of 5 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 675898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Lake Nursing Home 1611 W Royall Blvd Malakoff, TX 75148 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 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 store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Residents Affected - Some Baking sheets had thick, black burned on substances that were greasy and transferred grease when wiped with paper toweling. Cook A and DA B did not wear a beard restraint when in the kitchen or while serving food and preparing food trays. Mechanically altered chicken removed from the steam table by [NAME] A and placed on a insulated cover was returned to the pan on the steam table. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 07/10/23 of the kitchen the following was noted: *At 10:07 AM at the pan rack by the stove: 5 full size baking sheets were encrusted with thick, black burned substances. They were stacked together and were greasy to touch and when wiped with a paper towel transferred a greasy brown substance. There were 4 half-size baking sheets with a slight build-up of burned on substances, they were stacked together and greasy to the touch, and when wiped with a paper towel transferred a greasy brown substance. *At 10:15 AM DA B had a full facial beard and moustache. He was not wearing a beard restraint to contain facial hair and was preparing food trays for residents. During an observation on 07/10/23 at 11:45 AM [NAME] A had a full facial beard and moustache and was not wearing a beard restraint to contain his facial hair. He was cooking food and placing food on the steam table. DA B was not wearing a beard restraint to cover his beard and moustache and was placing items on residents' meal trays. During an observation on 07/10/23 at 12:55 PM [NAME] A scooped a serving of mechanically altered chicken from the steam table pan and placed it on an insulated plate holder instead of a plate. He dumped the chicken back into the steam table pan from the plate holder. He continued to serve the mechanical chicken to halls 200, 300 and 400. During an interview on 07/10/23 at 01:05 PM [NAME] A said he should not have put the chicken back into the steam table pan from the insulated holder. He said he realized it when he did it. He said he should have removed that chicken from the steam table and prepared fresh chicken to serve to the residents. During an interview on 07/10/23 at 01:08 PM the DM said when the cook contaminated the mechanical chicken he should have prepared more fresh chicken. She said she did not have any beard guards for the men to wear. She said they were not wearing them when she came to work at the facility last year and she asked them if they wore them and they told her they did not. She said she did not get any for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675898 If continuation sheet Page 4 of 5 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 675898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Lake Nursing Home 1611 W Royall Blvd Malakoff, TX 75148 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some them to wear. She said the baking sheets were fairly thick with burned on substances and she was not sure if she could get it all off so she said she would order new baking sheets. Review of a facility Food and Nutrition Services Staff Policy dated 10/2017 indicated 1. The food and nutrition services staff under the supervision of the dietitian and/or the food and nutrition services manager, will safely and effectively carry out the functions of the food and nutrition services department. Review of a facility Food Preparation and Service Policy dated 04/2019 indicated .7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Review of a facility Preventing Foodborne Illness Policy dated 10/2017 indicated 1. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness .12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . Review of a facility Sanitation Policy dated 10/2008 indicated .3. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675898 If continuation sheet Page 5 of 5