Health inspection·September 10, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 facility's only kitchen observed for kitchen sanitation.The facility failed to ensure the ice machine was cleaned and sanitized on a regular basis.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included: During an observation and interview on 09/08/2025 at 10:42 AM the ice machine in the steam table room had visible pink debris and dark brown specks present on the ice chute. A paper towel swipe of the chute, done by the surveyor, returned with pink and brown coloring. The DM said maintenance should be the one that took the machine apart and cleaned it with the chemicals. She said the dietary department wipes down the lid, gasket area, and outside of the machine daily or as needed. She said she had been at the facility a month and to her knowledge no one had broken the machine down to clean it.During an interview on 09/08/2025 at 10:55 AM DA A said maintenance deep cleans the ice machine in the steam table room and the dietary department wipes it down. He thought it had been about a month since it was cleaned about the time the new dietary manager came.During an interview on 09/08/2025 at 1:15 PM the Maintenance Supervisor said he thought dietary was responsible for cleaning the ice machine. He said the facility owned the ice machine and he said he thought he cleaned it maybe once that he knew of probably in December 2024.During an interview on 09/09/2025 at 9:15 AM the administrator said to his knowledge the facility did not have an outside vendor to clean the ice machine. He said the maintenance supervisor should do the maintenance cleaning. He said he had not told the maintenance supervisor he was responsible for deep cleaning the ice machine. He said the maintenance supervisor started working at the facility around January 2024 about a year and a half ago. He said he expected the dietary department to do the day-to-day cleaning of the lid, gasket area, and wiping down the outside of the machine. He said he did not know if he had the manufacturer's user manual but would see if the maintenance supervisor had it. He said the maintenance supervisor should be logging when the cleanings are done.Review of S Model Ice Machine Installation Operation and Maintenance Manual revised 12/2019 indicated under Section 4 Maintenance, Descaling and Sanitizing, General .Descale and sanitize the ice machine every six months for efficient operation.An extremely dirty ice machine must be taken apart for cleaning and sanitizing.Cleaning/Sanitizing Procedure .must be performed a minimum of once every six months. Detailed Descaling/Sanitizing Procedure must be performed a minimum of once every six months.Exterior Cleaning Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation.Sponge dust and dirt off the outside of the ice machine with mild soap and water. Wipe dry with a clean, soft cloth. Page 1 of 3 675898 675898 09/10/2025 Cedar Lake Nursing Home 1611 W Royall Blvd Malakoff, TX 75148

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #24) reviewed for infection control. CNA B failed to don PPE while transferring Resident #24 to the toilet and adjusted her urinary catheter drainage bag.This failure could place residents under their care at risk for the transmission of communicable diseases and infections. Findings included:Record review of a face sheet dated 09/2025 indicated Resident #24 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included retention of urine, fracture of 4th lumbar vertebrae, osteoarthritis of left knee, high blood pressure, and chronic pain. Record review of the admission MDS dated [DATE] noted Resident #24 had a BIMS score of 15 which indicated she was cognitively intact. The MDS indicated she required maximum assistance when toileting and was occasionally incontinent of bladder and continent of bowel.Record review of Resident #24's progress notes dated 08/01/2025 at 10:03 PM indicated the resident was unable to urinate and she said she had not urinated since the morning. Upon assessment, the resident's bladder was noted to be distended (overly full) and a new order was received from the nurse practitioner to insert a urinary catheter to check for residual urine. Residual urine was 400 cc of straw-colored urine. An order was given to insert an indwelling urinary catheter.Record review of Resident #24's physician orders, dated 09/08/2025, indicated an order dated 08/01/2025 for an indwelling Foley catheter care every shift, urinary output emptied and recorded every shift, and Foley catheter secured with catheter anchor every shift. A physician order dated 08/04/2025 indicated to the 16 French Foley catheter with 5 cc bulb be changed every month on the first of the month on the night shift starting 09/01/2025.Record review of Resident #24's care plan dated 08/03/2025 indicated she had an indwelling urinary catheter.During an observation and interview on 09/08/2025 at 11:10 AM Resident #24 returned from therapy to use the restroom. The resident said she was hoping to get the catheter removed this afternoon. She said they were hoping she could urinate afterwards so she didn't have to keep it in. CNA B came into the room, washed her hands, put on gloves and assisted the resident to sit on the toilet. The resident was able to transfer herself with some assistance and CNA B helped pull down her pull up. CNA B removed the drainage bag from the wheelchair to reduce tension on the catheter. CNA B did not don proper PPE before assisting Resident #24. CNA B said she was supposed to put on the PPE that was present in the room in the hanging bag when providing direct care to residents with a catheter. A hanging bag was observed attached to the closet door and it contained PPE supplies including gowns and gloves. She said she did not put on the gown only her gloves. During an interview on 09/09/2025 at 9:05 AM the ADON/IP said staff need to put on PPE when doing a transfer on a resident with a urinary catheter. She said Resident #24 had a urinary catheter but was continent of bowel and needed assistance to transfer to the toilet. She said the staff member should have put on a gown in addition to her gloves for the transfer.During an interview on 09/09/2025 at 9:10 AM the DON said EBP should be used according to their facility policy for residents with a urinary catheter, feeding tube, significant wound, etc. She said Resident #24 would require the staff to wear a gown and gloves during a transfer because she had an indwelling urinary catheter. Record review of the facility's undated policy titled Policy and Procedures - Infection Control Enhanced Barrier Precautions indicated the following: .use of gown and gloves during high contact resident care activities that include opportunities for transfer of MDROs to staff hands and clothing. High contact resident care activities include dressing, bathing, transferring, Residents Affected - Few 675898 Page 2 of 3 675898 09/10/2025 Cedar Lake Nursing Home 1611 W Royall Blvd Malakoff, TX 75148

F 0880 .changing briefs or assisting with toileting.Enhanced Barrier Precautions apply to:.wounds/indwelling medical devices (i.e., central line, urinary catheter, feeding tube tracheostomy/ventilator). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675898 Page 3 of 3