Health inspection·February 12, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety and pain medication. PRN (2) Tylenol 325mg as ordered and Ondansetron (medication used for nausea) 4mg. administered. MD notified, new order to obtain x-ray STAT. Mobile x-ray contacted. RP, DON, and unit manager notified. Record review of a mobile x-ray radiology interpretation report dated 10/24/23 indicated Resident #1 received an x-ray of the right femur. Impression of the x-ray indicated an acute comminuted fracture. Residents Affected - Few During an interview on 2/7/24 at 10:40 a.m. the DON stated she was not employed in the facility at the time of Resident #1's incident. The DON stated that staff were trained on hoyer lifts, and transfers using gait belts on hire. The DON said her expectations for staff utilizing the hoyer lift were to have 2 persons present, follow the procedures on the skilled checklist and make sure the wheelchair was in a locked position. During an interview on 2/7/24 at 10:48 am. LVN D said she had worked in the facility since August 2023. LVN D stated she was not working when Resident #1 had a fall, but all staff received mandatory training from the therapist on using the hoyer. LVN D stated all wheelchairs needed to be in a locked position prior to transferring a resident. During an interview on 2/7/24 at 11:20 a.m. the DOR stated that Resident #1 had been on therapy services 5/24/23-6/22/23. The DOR stated that after Resident #1 had her fall in October of 23, he did trainings and in-services on using the hoyer, and transfers. The DOR stated that the training was mandatory for all CNAs, MAs, nurses, and prn staff. The DOR stated that demonstrations were done on using the hoyer, as well as transfers, and staff did return demonstrations. The DOR stated he had 3 different training sessions, and checkoff sheets were reviewed and signed by him, and the employee. During an interview on 2/8/24 at 10:35 a.m. the SW stated that she was acting as interim ED at the time of Resident #1's fall. The SW stated that both CNA B and CNA C were asked to reenact what they did during the transfer of Resident #1. The SW stated she did not remember at what point they were asked to do this. The SW stated both CNA B and CNA C said they did not lock the wheelchair. The SW stated that the brakes should have been locked on the wheelchair at the time of the transfer. The SW stated neither CNA B nor CNA C said why the brakes were not on at the time. The SW stated both CNA B and CNA C were terminated. The SW stated a QA meeting was called the afternoon of the incident and training was initiated. During an interview on 2/8/24 at 11:03 a.m. GVN E stated she had worked in the facility since January of this year. GVN E stated she had received training on hoyer lifts and transfers when she hired on. GVN E stated 2 people were required for all hoyer transfers. The resident is placed on the hoyer pad while in bed, the pad is then secured to the hoyer. I always make sure the pad is intact and secured appropriately to the hoyer. One employee operates the lift and the other staff guide the resident to the wheelchair, which is to be locked and the footrests open before transfer. During an interview on 2/8/24 at 11:20 a.m. the Maintenance Supervisor stated he had worked in the facility for 14 months. The Supervisor stated he had been asked to observe all the wheelchairs in the facility in October 2023. The Supervisor stated on 10/25/23 he checked wheelchairs for any loose brakes and adjusted/tightened any that were loose, and all brakes were found to be in working order. The Supervisor stated there were 6 hoyer lifts in the facility, and there was a company that came out quarterly to do any maintenance needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 2 of 6 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 675519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larkspur 201 South John Redditt Drive Lufkin, TX 75904 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an observation and interview on 2/8/24 at 1:05 p.m. MA/CNA F, and CNA G were observed during a hoyer transfer on Resident #2 from wheelchair to bed. There were no issues identified. Both MA/CNA F, and CNA G stated they were hired in December of 2023. Both MA/CNA F, and CNA G stated they had received training when hired on hoyer lifts and transfers. Both MA/CNA F, and CNA G stated that the wheelchair should have brakes locked when transferring a resident in the hoyer. During an observation and interview on 2/12/24 at 8:45 a.m. CNA H said she had worked in the facility 1 ½ years. During the same interview, Restorative aide M said she had worked in the facility for 14 years. CNA H and Restorative aide M were observed during a wheelchair transfer on Resident #3. Resident #3 was transferred from her wheelchair to her bed. CNA H explained what they were doing, and both washed their hands prior to transfer. The footrests were removed from the wheelchair and a gait belt was placed on Resident #3. The wheelchair was locked on both sides. Resident #3 was safely transferred to the bed with no issues. The bed was placed in a low position and call light placed near Resident #3. Both CNA H and Restorative aide M stated they had received training on transfers and using the hoyer lift and had to do hands on demonstrations and signed skills check off form. Restorative aide M stated that all staff were provided a gait belt. Resident #3 stated she felt safe during her transfer, and they do a good job. During an observation and interview on 2/12/24 at 9:05 a.m. CNA H and Restorative aide M were observed during a hoyer lift on Resident #2 from her wheelchair to her bed. No issues were identified. Resident #2 was unable to answer any questions appropriately. During an observation and interview on 2/12/24 at 9:25 a.m. CNA J said she had worked in the facility for 1 ½ months. CNA K said she had worked in the facility for 1 year. Both aides stated they had received training on using the hoyer lift and doing transfers when they were hired. CNA J and CNA K were observed doing a hoyer transfer on Resident #4. CNA J stated Resident #4 had agreed to get up in the wheelchair, and then be placed back to bed so observation could be done. The transfer to wheelchair and back to bed were observed with no findings. Resident #4 stated she always got nervous when being transferred with the hoyer but had not had any recent problems. Resident #4 stated a long time ago, I can't remember when, the pad broke while I was in the shower. Resident #4 stated she was not hurt, and the staff was good about explaining everything they did. During an observation and interview on 2/12/24 at 9:57 a.m. CNA J was observed doing a bed to wheelchair transfer, and wheelchair to bed transfer on Resident #5. There were no issues identified. Resident #5 stated he felt comfortable with staff transferring him, as he could not do it by himself. Resident #5 stated, this aide is good! Watch her, you will learn a lot from her. During an observation and interview on 2/12/24 at 10:08 a.m. CNA H and CNA L were observed doing a hoyer transfer on Resident #6. There were no issues identified. Resident #6 was non-interviewable. During an observation and interview on 2/12/24 at 10:27 a.m. CNA L was observed doing a bed to wheelchair transfer using a sliding board on Resident #7. There were no issues identified. Resident #7 stated he was receiving therapy but was not able to transfer to his wheelchair by himself at this time. Resident #7 stated he did not like using the hoyer lift as it made him nervous, and using the transfer board made it a lot easier and made him feel more comfortable. During a phone interview on 2/12/24 at 11:24 a.m. CNA B stated she remembered the incident with Resident #1. CNA B stated Resident #1 fell on CNA C and both of us were terminated. CNA B stated, the other girl admitted she did it. CNA B stated the other aide was setting Resident #1 down, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 3 of 6 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 675519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larkspur 201 South John Redditt Drive Lufkin, TX 75904 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wheelchair started to tilt and Resident #1 landed on the other CNA. CNA B stated after Resident #1 was on the floor, they grabbed Resident #1 and put her in the wheelchair. She stated Resident #1 did not complain of any pain. CNA B stated Resident #1 could feed herself but was total care. CNA B stated when she was hired, she had received training on the hoyer lift, and transfers. CNA B stated the brakes on the wheelchair were unlocked, and that the brakes to the hoyer were on. CNA B stated the wheelchair brakes should have been on. One side was locked; the other side of the chair was not. The other aide said it was her fault. CNA B stated the wheelchair moved out behind Resident #1 as they were lowering her into the wheelchair. I don't remember what caused it to move. The chair was locked on my side, but not the other side. CNA B stated, if the wheelchair was locked, this probably would not have happened. CNA B stated she knew the wheelchair should have been locked, and not sure why the other side wasn't. During a phone interview on 2/12/24 at 11:34 a.m. CNA C was contacted and voicemail was left. On 2/12/24 at 11:35 a.m. CNA C returned the call. CNA C said she remembered the incident, and stated this happened months ago, and you are just now calling me? CNA C stated she was at work and would return call when she got off around 3:30 p.m. on this date. CNA C did not return call. Record review of a Grievance Report dated 10/24/23 and signed by the SW indicated .Resident #1's RP was notified of a fall that Resident #1 had that was witnessed by the staff transferring her. Family member stated that she was on her way at that time. Upon arrival to the facility, family stated that the Resident told them that she fell during transfer and that they believe she was not transferred with the hoyer. Family then stated that they did not want the aides that did transfer in Resident #1's room. Family member went on to state that she had bail money and I am going to jail today. Both CNAs state that a hoyer transfer was completed and that the resident slipped out of the wheelchair during the transfer. Both aides provided written statements regarding the transfer Record review of an Accident/Incident Report dated 10/24/23 and signed by LVN A indicated the following: .Account of Occurrence- CNAs report that Resident was being transferred via hoyer lift x2 nurse aides, wheels on wheelchair were not locked, and as aide was lowering Resident down in wheelchair, Resident #1 slid out of the chair. As the aide went to catch her, the aide and Resident #1 both went to the ground. Upon assessment, resident complained of pain to the RLE above her amputation site. Resident denies any other pain. Resident was assisted back to wheelchair. PRN pain medicine administered. Received order from MD for STAT x-ray . Record review of a witness statement dated 10/24/23 signed by CNA B revealed the following, I was in the room with Resident #1 and CNA C and I were getting Resident #1 up to put her in the chair and as CNA C was lowering Resident #1 down, she slid out of the chair and CNA C grabbed Resident #1, and Resident #1 fell on top of CNA C, and they both fell on the floor. Record review of an undated witness statement signed by CNA C revealed the following, I CNA C was getting Resident #1 up to put her in her chair. As I was lowering Resident #1 down, she slid out of the chair and I was there to grab her, and me and Resident #1 both fell to the ground. Record review of a Personal Action Form indicated CNA B was terminated with last day worked listed as 10/24/23. Record review of a Personal Action Form indicated CNA C was terminated with last day worked listed as 10/24/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 4 of 6 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 675519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larkspur 201 South John Redditt Drive Lufkin, TX 75904 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of a Mechanical Lift Competency Skills Checklist dated 2/27/07 indicated When transferring from or to a wheelchair, shower chair or bed, make sure that wheelchair, shower chair or bed is locked . Record review of the hoyer service provider Certification of Calibration forms indicated visits were made on 10/10/23, and 1/2/24. Record review of a Quality Assurance and Performance Improvement Meeting Minutes form indicated a meeting was held on 10/24/23 at 4:30 p.m. with the following members were present; DON, activity director, care plan/MDS nurse, nutritional services director, HR, interim ED, unit manager, and financial manager. Report also indicated the incident was discussed with the Medical Director over the phone. The following interventions were put in place: Steps taken regarding the incident with completion dates included: Resident assessed immediately- completed 10/24/23 Physician contacted and orders received-completed 10/24/23 PRN pain medication administered-completed 10/24/23 In-services initiated on abuse/neglect- started 10/24/23, completed 10/26/23 In-services initiated on Hoyer transfers- started 10/24/23, completed 10/26/23 In-services initiated on stand-pivot transfers and gait belts- started 10/24/23, completed 10/26/23 In-services initiated on assessment- started 10/24/23, completed 10/26/23 100% audit conducted by maintenance on wheelchair brakes-completed 10/25/23 Audit of Hoyer pads-started 10/24/23, completed 10/25/23 Audit of Hoyers in the facility- started 10/24/23, completed 10/25/23 Grievance completed-completed 10/24/23 Reported to HHSC-completed 10/24/23 Ombudsman notified-completed 10/24/23(message left) spoke to her 10/25/23 Resident sent to hospital-completed 10/24/23 Both aides suspended pending investigation-completed 10/24/23-both terminated Safe surveys initiated-completed 10/25/23 Resident interviews initiated (part of safe surveys) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 5 of 6 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 675519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larkspur 201 South John Redditt Drive Lufkin, TX 75904 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 0689 Psychosocial assessment completed prior to resident leaving facility-completed 10/24/23 Level of Harm - Immediate jeopardy to resident health or safety Inservice on daily care guide- started 10/24/23, completed 10/26/23 Record Review of In-service Training Reports indicated training was done on safe transfers, Abuse/Neglect, Assessment, Activities of Daily Living-Daily Care Guide, and Accidents/Incidents. Residents Affected - Few Trainings were initiated on 10/24/23 and were completed on 10/26/23. A review of Mechanical Lift Competency Skills Checklist, and Transfer Skills Checklist indicated training was initiated on 10/25/23 and completed on 10/26/23. Training records indicated 50 employees received training. The noncompliance was identified as PNC. The Immediate Jeopardy began on 10/24/23 and ended on 10/26/23. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 6 of 6