Health inspection·March 6, 2024

F 0553 Level of Harm - Minimal harm or potential for actual harm revised September 2013, read .The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 2 of 16 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 03/06/2024 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 4 residents reviewed for misappropriation of property. (Resident #124). Residents Affected - Few The facility failed to prevent a diversion (misappropriation) of Resident #124's Zofran tablets (used to treat nausea and vomiting) a total of 4 tablets. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #124 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly and it causes a low number of red blood cells or a low amount of hemoglobin in your red blood cells). Record review of a Comprehensive MDS assessment dated [DATE] indicated that Resident #124 had a BIMS score of 15 which indicated that she was cognitively intact. Record review of a physician order report dated 3/6/24 for Resident #124 indicated that she had a physician order for ondansetron (Zofran) 4mg disintegrating tablets, 1 tablet as needed every 6 hours for nausea with a starting date of 2/27/24. Record review of Medication Administration Records for Resident #124 for the months of February 2024 and March 2024 indicated that she did not receive any doses of Zofran. During an observation on 3/5/24 at 3:54 pm the state surveyor randomly chose 3 narcotic cards to compare to count book on nurse's medication cart. No discrepancies were found. During an observation on 3/6/24 at 2:00 pm 7 tablets of Zofran in individual blister packs were observed in the DON's office. These were found in LVN B's personal belongings on 3/4/24 by the DON and the Administrator. A label with Resident #124's identifying information was stuck to 2 of the tablets. Also observed was an empty package with Resident #124's prescription information indicating that it had been filled on 2/27/24 with a quantity of 4 tablets. This packaging had been found in the trash after finding the tablets in LVN B's possession. A telephone interview was attempted on 3/6/24 at 9:55 am with LVN B. No answer was received, a voicemail was left requesting a return phone call. Another attempt was made at 2:18 pm on 3/6/24, the phone rang twice, then disconnected. The state surveyor was unable to leave a voicemail at this time. No return phone call was received before exit. During a telephone interview on 3/6/24 at 2:18 pm, CNA A said that on 3/4/24 she had witnessed LVN B at the medication cart and heard a pop .pop .pop . like she was removing medications. She then witnessed LVN B go to the nurse's station and sit down. CNA A said that LVN B always kept her purse at the nurse's station. She said that she then heard what sounded like LVN B putting medications in a bottle. She said that she immediately went to the DON to report the allegation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 3 of 16 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 03/06/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/6/24 at 2:30 pm the DON said that she had immediately went to LVN B with the RNC and the Administrator. She said that they asked her about the allegation, which LVN B denied. She said that LVN B agreed to let them look in her purse. She said that she found LVN B's personal medications along with 7 tablets of Zofran in separate blister packs along with Resident #124's identifying prescription information. She said that LVN B said that she did not know how the medication got there. The DON said that LVN B was counseled, and drug tested with permission. She said that LVN B was suspended pending investigation, but LVN B voluntarily terminated at that time. The DON said that she also found an empty package with Resident #124's prescription information in the trash on LVN B's medication cart. She said that the package was empty and had been filled with 4 tablets. She was unsure where the other 3 tablets of Zofran came from. She said that they had looked through the narcotics and did not find anything else missing. She also said that they had called the pharmacy consultant to come in and do a review. During an interview on 3/6/24 at 2:53 pm the Administrator said that the CNA had reported the allegation to the DON. He said that he went with the DON to the nurse and LVN B denied the allegations. He said that they asked to look in her purse. He said that they went into an empty resident room and emptied her bag out. He said that all of LVN B's personal medications were in there along with the Zofran tablets for Resident #124. He said that LVN B said that they weren't hers. He said that they then did a cart count with the DON, LVN B, and himself and all counts were accurate. He said that the incident was reported to the police, and they started education and in-services. He said that they will be doing random spot-checks to hopefully prevent incident from occurring again. During an interview on 3/6/24 at 3:00 pm the RNC said that she had called the consultant pharmacist regarding the incident and that he would be coming next week to do a review. Record review of a facility policy titled Identifying Exploitation, Theft ,and Misappropriation of Resident Property dated 2001, revised April 2021 read .'Misappropriation of resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . and .Examples of misappropriation of resident property includes: .drug diversion (taking the resident's medication) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 4 of 16 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 03/06/2024 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months or 92 days) using the MDS (minimum data set) form specified by the state and approved by CMS (Centers for Medicare & Medicaid Services) for 1 of 6 residents (Resident # 271) reviewed for quarterly assessments. Residents Affected - Few The facility failed to ensure Resident # 271 had a quarterly MDS assessment completed within 3 months or 92 days from the previous assessment that was completed on 07/26/2023. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings included: Record review of a facility face sheet dated 3/06/2024 indicated Resident #271 was a [AGE] year-old male and admitted to the facility on [DATE] with a diagnosis of cervical disc disorder (disorder of the bones in the neck). Record review of the MDS assessment list indicated Resident #271 had an admission MDS assessment completed on 7/26/2023 however did not receive a quarterly assessment until 12/22/2023. A quarterly MDS assessment was due on or before 10/26/2023. During an interview on 03/06/2024 at 2:29 PM the MDS coordinator stated that she started at the facility at the end of October 2023 and was not sure why Resident #271 did not have a quarterly MDS assessment completed. She stated Resident #271 was on managed care and may have been the reason it was missed. She stated that all residents should get a MDS Assessment within 14 days of admission, quarterly every 92 days and as needed for any significant change in condition, despite payor source. She stated if MDS assessments were not done accurately it could affect resident care. During an interview on 03/06/2024 at 2:42 PM the RCC (regional care coordinator) stated he oversaw the MDS nurse at the facility. He stated the previous MDS nurse missed the quarterly MDS assessment on Resident #271. He stated Resident #271 should have had an assessment within 92 days of the completion of the admission assessment. He stated the facility had not had a full time MDS nurse until October 2023 and assessments were being completed offsite. He stated when the MDS system changed in October 2023 they had software issues and that could have been the cause for it being missed. He stated if assessments were not done the care plan would not be accurate and could affect resident care. He stated he expected the MDS nurse to follow and track the assessments to ensure they were done per the regulations. During an interview on 03/06/2024 at 4:55 PM the administrator stated that the MDS coordinator was responsible but at that time the MDS assessments were done off site and he was not sure how MDS assessments were monitored. He stated the RCC assisted the MDS nurse with the assessment schedules and if a MDS assessment was not done per timeframes the care plan would not be up to date. He stated he expected the MDS nurse to follow the timeframe for all MDS assessments. He stated the facility did not have a policy for MDS timeframes and submission and followed the RAI (resident assessment instrument) manual for MDS assessment completion and submission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 5 of 16 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 03/06/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #63) reviewed for indwelling catheters. The facility failed to prevent Resident #63's urinary catheter drainage bag from touching the floor. These failures could place residents at risk for inappropriate placement of indwelling catheters, discomfort or injury, and urinary tract infections. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #63 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of essential hypertension (high blood pressure). Record review of a Comprehensive MDS Assessment for Resident #63 dated 1/8/24 reflected that he had a BIMS score of 7, which indicated that he had severe cognitive impairment. Section H indicated that he used a urinary catheter. Record review of a Comprehensive Care Plan dated 3/6/24 for Resident #63 indicated that it did not address the use of a urinary catheter. During an observation on 3/4/24 at 12:20 pm Resident #63 was observed sitting at a table in the dining room with his drainage bag underneath his wheelchair, touching the floor. A restorative aide was observed to remove the resident from the dining room and push him down the hallway with the drainage bag dragging on the floor. During an observation on 3/4/24 at 2:47 pm, Resident #63 was observed lying in bed asleep with his bed in low position. Urinary drainage bag was observed to be hanging from the bed with the bottom of the bag on the floor. During an observation on 3/5/24 at 9:04 am, Resident #63's drainage bag was noted to be hanging from the bed and the drainage bag touching the floor. During an interview on 3/5/24 at 9:20 am, LVN C said that she would get with the DON to see what to do about the bag being on the floor. She said that his bed needed to stay in the low position. She said that the bag should not be placed on the floor and by being on the floor, it could increase the risk for infections. During an interview on 3/5/24 at 9:25 am the DON said that she would figure out some way to keep his bag off the floor. She said that she understood that the bag being on the floor increased the risk for infection. She said that she expected her staff to follow policy of keeping the bag off the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 6 of 16 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 03/06/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/6/24 at 11:00 am the DON said that they had ordered some low bed specific drainage bags and would be using a basin or a tub until they came in to keep the bag off the floor. She said that she would also be providing in-services for education for nursing staff regarding this. During an interview on 3/6/24 at 2:53 pm the Administrator said that the catheter bag should not be on the floor because it could cause infection, or the bag could tear or leak. He said that he would plan on doing observations and implementing education to help prevent this. Record review of a facility policy titled Catheter Care, Urinary dated 2001, revised September 2014 read .be sure the catheter tubing and drainage bag are kept off the floor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 7 of 16 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 03/06/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 2 of 13 residents reviewed for respiratory care (Residents #7 and #122). Residents Affected - Few 1.The facility failed to ensure Resident #7's nebulizer mask was changed per the facility's policy. 2.The facility failed to ensure Resident #122's humidifier bottle and tubing for the oxygen concentrator were changed per the facility's policy and Physician orders. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings included: 1.Record review of a facility face sheet dated 3/6/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction (weakness/paralysis due to a stroke). Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. Section O indicated that she had received nebulizer treatments for at least 15 minutes for 7 of the previous 7 days of the assessment reference date (2/6/24). Record review of Medication Administration Records for Resident #7 for February 2024 and March 2024 indicated that she received twice daily nebulizer medications. During an observation and interview on 3/4/24 at 10:44 am, Resident #7 was observed lying in bed. A nebulizer mask was observed on her bedside table in a bag which was dated 1/7/24. Resident #7 was unable to say if she used it often. She said that she could not remember. 2.Record review of a facility face sheet indicated Resident #122 was an [AGE] year-old female and admitted to the facility on [DATE] with a diagnosis of COPD (group of lung disease that make it difficult to breathe). Record review of a quarterly MDS assessment dated [DATE] indicted Resident #122 had an impairment in thinking with a BIMS score of 12 - and had special treatments, procedures, and programs that included oxygen therapy as a resident within the last 14 days. Record review of comprehensive care plan with revision date of 12/18/24 indicated Resident #3 had COPD (chronic obstructive pulmonary disease that affects breathing). Record review of a consolidated physician's order list for Resident #122 indicated an order dated 01/17/2024 to administer oxygen 2-4 liters per minute by nasal cannula and change/date oxygen tubing one time weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 8 of 16 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 03/06/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 03/04/24 at 10:19 am revealed Resident #122 had oxygen on at 4 liters via nasal cannula. The oxygen tubing was not dated and humidified water bottle was dated 02/18/24 and dry. Resident #3 stated she wore her oxygen all the time and did not know when the bottle or tubing had been changed. Residents Affected - Few During an observation 03/04/24 2:00 PM humidifier bottle remained dry and dated 02/18/24. During an observation on 03/06/24 10:30 AM the humidifier bottle was full of water and bubbling. The bottle and O2 tubing were dated 03/05/24 and O2 on at 4 liters per nasal cannula . During an interview on 3/06/2024 at 2:20 pm, the DON stated the charge nurses were responsible for changing the oxygen tubing and humidifier bottles weekly. She stated by not doing so could cause oxygen delivery issues or infections . The DON said she was responsible for ensuring processes are in place. During an interview on 3/06/2024 at 3:00 pm, the Administrator said nursing was responsible for cleaning the oxygen concentrators, changing the tubing and bottles every Sunday, and as needed. He said the DON was to oversee that the nursing staff were following the respiratory care policy and expected respiratory equipment to be cleaned and changed weekly. He said she would have the DON or designee do an audit to check that they were done. He said the residents could be at risk for inadequate air flow if the concentrators were not cleaned and infections. Record review of a facility policy titled Administering Medications through a Small Volume (handheld) Nebulizer dated 2001, revised October 2010, read .Change equipment and tubing every 7 days . Record review of a facility policy dated October 2010 and titled Oxygen Administration indicated, . Purpose the purpose of this procedure is to provide guidelines for safe oxygen administration .12. Check the mask, tank, humidifying jar etc., to be sure they are in good working order, and securely fastened. Be sure water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 9 of 16 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 03/06/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 12 months (January 2024) reviewed for pharmacy services. The facility failed to properly inventory drugs at time of disposal on 1/31/24. This failure could put residents at risk for misappropriation and drug diversion. Findings included: Record review of facility drug destruction records dated February 2023 through February 2024 revealed that on January 31, 2024, the attached pages were only signed by the consultant pharmacist and contained no witness signatures or initials. During an interview on 3/6/24 at 11:00 am, the DON said that she had only been in this position for a couple of months, and going forward she would ensure that correct policies and procedures were followed for drug destruction. She said that without following proper procedures, there could possibly be a drug diversion. During an interview on 3/6/24 at 2:53 pm, the Administrator said that going forward he would plan to be present during drug destruction. He said that the DON was responsible for drug destruction. He said that there could be a drug diversion if not done correctly with 2 witnesses. Record review of a facility policy titled Drug Destruction dated September 2013 read .The consultant pharmacist seals the container in the presence of two authorized witnesses . Record review of 22 TAC §303.1 Destruction of Dispensed Drugs accessed online 06/07/2023 at https://texreg.sos.state.tx.us/ indicated. (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (ix) signature of the witness(es); and C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet , provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 10 of 16 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 03/06/2024 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 0755 v) any two individuals working in the following capacities at the facility: Level of Harm - Minimal harm or potential for actual harm (I) facility administrator. (II) director of nursing. Residents Affected - Few (III) acting director of nursing; or (IV) licensed nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 11 of 16 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 03/06/2024 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 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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. Residents Affected - Many The facility failed to date six packages of white cake mix and two packages of gelatin mix that were in the dry storage area on 3/4/2024. The facility failed to ensure the DM and [NAME] wore a hairnet effectively to cover all of their hair on 3/5/2024. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation on 3/4/2024 at 9:10 AM in the kitchen, the dry storage area had six packages of white cake mix and two packages of gelatin mix that were removed from the original box that was not dated. During an interview on 3/4/2024 at 9:30 AM, the DM said everyone that worked in the kitchen were responsible for dating and labeling items and staff were aware not to put anything up without dating and labeling. During an observation and interview on 3/5/2024 at 11:15 AM, the [NAME] was pureeing food for lunch and the DM was present in the kitchen assisting as needed and both did not have their hair completely covered with the hairnet. They both had hair sticking out from underneath the hair net on the sides of both of their ears and at the back of their necks . The cook said all hair should be covered by the hairnet prior to entering the kitchen and by not doing so could cause cross contamination. During an interview on 3/5/2024 at 2:45 PM, the DM said all staff as soon as they entered the kitchen must put on a hairnet and make sure it completely covered their hair. She said they in-serviced staff on hairnets and labeling of foods on 3/5/2024. She said there could be a risk of hair falling into the food if hair was not completely covered while in the kitchen. Record review of in-service training report dated 3/5/2024 conducted by the DM indicated the kitchen staff were trained on dating and labeling: all items must have date and label before storing. Training also included hair nets: hair nets must be worn while in the kitchen. All hair must be covered. During an interview on 3/6/2024 at 11:50 AM, the Administrator said he was made aware of the items in the kitchen that were not dated and the staff not wearing hairnets appropriately. He said it was the responsibility of the DM for ensuring the foods were dated or whoever put up the food in the kitchen. He said all staff in the kitchen should be wearing hairnets when in the kitchen area. He said hair could fall into food while preparing. He said not dating items depended on the expiration dates of the items. He said going forward they would educate the staff and conduct audit checks between him, the DM, and the RD. Record review of a facility policy titled Food Storage revised 3/2019 indicated, .4. All food items should be dated with the received dated, unless labeled with a readable label from the food vendor . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 12 of 16 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 03/06/2024 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 0812 Record review of a facility policy titled Employee Sanitary Practices dated November 3, 2004, indicated, .All employees shall: 1. Wear hair restraints . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 13 of 16 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 03/06/2024 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 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 review, 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 6 residents (Resident #271) and 1 of 7 staff (CNA E) reviewed for infection control. Residents Affected - Few CNA E failed to perform hand hygiene while performing incontinent care to Resident #271 on 03/05/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a facility face sheet dated 3/06/2024 indicated Resident #271 was a [AGE] year-old male and admitted to the facility on [DATE] with a diagnosis of cervical disc disorder (disorder of the bones in the neck). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #271 had a BIMS of 15 indicating intact cognition and was incontinent of urine and bowel requiring moderate assistance with toileting. Record review of the care plan dated 7/26/2023 indicated Resident #271 had an ADL (activity of daily living) function disorder and to assist with ADL's as needed. During an observation on 03/05/2024 at 9:20 AM CNA E provided incontinent care to Resident # 271. CNA E washed her hands and applied gloves. She opened Resident #271's solid brief and cleaned his front peri area with wipes. Resident #271 rolled to his right side and CNA E cleaned his buttocks and peri area with wipes. CNA E removed her soiled gloves, applied clean gloves without hand hygiene, and applied Resident #271's clean brief. CNA E then assisted Resident #271 with getting dressed and transferred him to his wheelchair. CNA E removed her gloves and washed her hands before leaving the room. During an interview on 03/05/2024 at 9:27 AM CNA E stated she had been a CNA for 29 years and had worked at the facility for 4 months. She stated she had been trained on incontinent care and hand hygiene and she should have washed her hands before applying clean gloves. She stated she had her sanitizer on the table and got nervous and forgot. She stated that by not performing hand hygiene between glove changes it could cause infections. During an interview on 03/06/2024 at 2:06 PM the DON stated CNA's were trained on hire, annually, and CNA E successfully passed skills training last week for hand hygiene and incontinent care. She stated she was responsible for oversight in the building for infection control and if infection control measures were not followed it could lead to infections. She stated she expected all staff to follow infection control measures for resident care. During an interview on 03/06/2024 at 4:53 PM the administrator stated infection control oversight was the responsibility of the DON. He stated if infection control measures were not followed it could cause infections and expected that infection control measures were followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 14 of 16 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 03/06/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of a skills checklist for perineal care dated 02/28/2024 indicated CNA E was trained and competent in perineal care and hand hygiene with glove use. Record review of a facility policy titled Handwashing/Hand Hygiene dated August 2019 indicated, .this facility considers hand hygiene the primary means to prevent the spread of infections. 7. use an alcohol-based hand rub or soap and water for the following situations: m. after removing gloves . Event ID: Facility ID: 675519 If continuation sheet Page 15 of 16 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 03/06/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 1 of 6 residents reviewed for call lights. (Resident #4). Residents Affected - Few The facility failed to ensure Resident #4's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #4 indicated that she was a [AGE] year-old woman admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Section GG indicated that she required supervision assist with toileting. Record review of a comprehensive care plan dated 3/6/24 for Resident #4 indicated that she was at risk for falls related to generalized weakness and limited mobility. Interventions included .Place call bell/light within easy reach . Record review of a facility accident and incident log dated 12/1/23 through 3/5/24 indicated that Resident #4 had not sustained any falls within that time period. During an observation and interview on 3/4/24 at 10:28 am the call light in the bathroom was observed to have no cord. Resident #4 said that she does use the restroom. During an interview on 3/4/24 at 10:33 am GVN D said that she had been employed here for about 2 months. She said that Resident #4 does use the restroom independently at times. She said that there should be a string on the call light so that it can be used to call for help. She was unsure how long it had been that way. She said that she would report it to maintenance to have it fixed. During an interview on 3/6/24 at 11:00 am the DON said that they would be initiating administrative rounds to ensure all call lights were within reach and working properly. She said that they would also ensure that all bathroom call lights were accessible. She said that if they were not accessible, that it could lead to a delay in resident care. Record review of a facility policy titled answering the call light dated 2001, revised October 2010, read .Explain to the resident that a call system is also located in his/her bathroom . and .be sure the call light is within easy reach of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 16 of 16