Inspection·August 7, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 2 of 4 residents (Residents # 24 and 41) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately code Resident # 24's and Resident # 41's nutritional status for weight loss on the MDS assessments. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #24's face sheet dated 08/07/2024 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included anorexia (an eating disorder characterized by an abnormally low body weight), debility (physical weakness), and Failure to Thrive (a syndrome that describes a gradual decline in physical and cognitive function that is characterized by weight loss, malnutrition, and debility). A review of Resident #24's weight records indicated she weighed 95.4 pounds on 01/08/2024. Resident # 24's weight on 07/02/2024 was noted to be 84.2 pounds, indicating a weight loss of 11.2 pounds (11.7%) in the last 6 months. A review of a dietary note completed by the RD on 07/12/2024 for Resident #24 indicated Resident #24's July 2024 weight reflected a loss of 11.2 pounds which calculated as a 11.7% weight loss in the last 6 months. A review of Resident #24's Dietary Quarterly Review completed by the facility's DM on 07/24/2024 indicated Resident #24 had no weight loss in the last 6 months. A review of Resident #24's Quarterly MDS assessment (Section K 0300) dated 07/31/2024 indicated Resident #24 had not had a weight loss of 10% in the last 6 months. 2. A review of Resident #41's face sheet dated 08/07/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, chronic obstructive pulmonary disease (a group of diseases that block airflow making it difficult to breathe), and pneumonia. A review of Resident #41's weight records indicated he weighed 124.8 pounds on 06/05/2024. Resident (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 6 Event ID: 675898 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 08/07/2024 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)