Cycle 1
Health 2025-09-10 · Fire 2025-09-10
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Malakoff, TX
Cedar Lake Nursing Home
4-star overall rating with 5-star inspections with $31,850 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1611 W Royall Blvd, Malakoff, TX
(903) 489-1702
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fannin County Hospital District
Operator or chain grouping
Approved since
2001-11-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.33
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.86
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.51
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
5.22
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,568
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.84
Baseline 24.70% · Performance 19.83% · Measure score 5.84 · Achievement 3.45 · Improvement 5.84
Healthcare-associated infections
0
Baseline 4.59% · Performance 8.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.98
Baseline 3.84 hours · Performance 3.93 hours · Measure score 2.98 · Achievement 2.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 10.17% · Lower 95% interval 7.28% |
| Discharge to community | 43.47% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 38.3% · Lower 95% interval 32.18% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 54.17% |
53.69%
0.5 pts better
|
Numerator 13 · Denominator 24 |
| Discharge mobility score | 20.83% |
50.94%
30.1 pts worse
|
Numerator 5 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 9.68% |
2.29%
7.4 pts worse
|
Numerator 3 · Denominator 31 · Adjusted rate 7.87% |
| Healthcare-associated infections requiring hospitalization | 8.46% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 13.79% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 6 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.1
1.9 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
97.1%
2.2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.3%
1.9 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.8% · Q3 4.7% · Q4 7.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 12.0% |
3.3%
8.7 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 16.0% · Q3 3.7% · Q4 17.9% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.3% |
18.9%
3.4 pts worse
|
19.6%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 24.0% · Q3 23.3% · Q4 20.7% · 4Q avg 22.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
10.8%
4.5 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.0% · Q3 15.0% · Q4 18.2% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 45.0% |
15.4%
29.6 pts worse
|
16.3%
28.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 45.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.0% |
16.1%
7.9 pts worse
|
14.9%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 13.6% · Q3 25.9% · Q4 28.0% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.8%
0.5 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
15.0%
14.7 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.7% · Q2 30.5% · Q3 32.4% · Q4 15.1% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.2%
2.1 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.3% · Q3 5.5% · Q4 6.8% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.7%
9.3 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
12.0%
4.5 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.8% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
88.0%
10.2 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
25.9%
3.4 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 28.9% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-07 · Fire 2024-08-07
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-12 · Fire 2023-07-12
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-12-20
F · Potential for more than minimal harm
2025-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-09-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-12-17
F · Potential for more than minimal harm
2024-08-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-08-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-30
F · Potential for more than minimal harm
2024-08-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-07
D · Potential for more than minimal harm
2024-08-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-07
D · Potential for more than minimal harm
2024-08-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-07
E · Potential for more than minimal harm
2023-07-12
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-07-12
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-07-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-31
Penalties and ownership
What sits behind the stars
$4,545
2023-08-21
Fine
Fine · fine $4,545
Fine
$4,545
2023-08-14
Fine
Fine · fine $4,545
Fine
$4,545
2023-08-07
Fine
Fine · fine $4,545
Fine
$13,635
2023-07-17
Fine
Fine · fine $13,635
Fine
$4,580
2023-03-20
Fine
Fine · fine $4,580
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Blalock, Edward
Operational/Managerial Control · Individual
Bumpass, Michael
5% Or Greater Mortgage Interest · Individual
Bumpass, Ursula
5% Or Greater Mortgage Interest · Individual
Mummm Investments, LLC
5% Or Greater Mortgage Interest · Organization
Rusk Nursing & Rehab Center LLC
Operational/Managerial Control · Organization
Sanderson, Clark
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Avir at Athens
Athens, TX
2-star overall rating with 3-star inspections with $243,325 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Park Highlands Nursing & Rehabilitation Center
Athens, TX
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Advanced Rehabilitation And Healthcare Of Athens
Athens, TX
1-star overall rating with 1-star inspections with $124,017 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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