Health inspection·January 7, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriate state agency, immediately suspended CNA A pending investigation, notified police department. The facility investigation included copies of completed employee- Abuse, Neglect & Exploitation in-service 05/11/24 and 5/12/24 with emphasis on misappropriation, documentation of completed resident interviews, documentation of completed resident safety surveys that indicated no reports of misappropriation by other residents and the residents interviewed felt safe at the facility, and a copy of employee disciplinary action form for suspension of CNA A on 05/10/24 completed per phone call. During a phone interview on 01/06/25 at 2:20 p.m., Resident #1 said she was a resident at the facility last May but was currently living at home. Resident #1 said last May she was planning to be discharged , when she asked CNA A to help her look at rent houses on her phone. After they viewed a few properties, CNA A proceeded with incontinent care, and she placed Resident #1's cell phone on the bedside table behind her. Resident # 1 said that it seemed like the care was taking too long and she became suspicious of what CNA A was doing. Resident #1 said after the care was completed, she looked at her phone and she had received a notification from her cash app that a $106.00 withdrawal/ scam alert. She said the money was returned to her account in less than an hour, after she confronted CNA A and alerted facility staff CNA B and LVN C. Resident #1 said she was very pleased how the facility handled the incident. She said that she received no harm due to the incident and she has had two additional short term stays at the facility since this incident. During interview with the DON on 01/07/25 at 2:30 p.m., the DON confirmed that CNA A never acknowledged she had taken the money, never returned to work, and was terminated via a phone call 05/16/24. The DON confirmed that police were notified (case # 24-00014617). During an observation and interview on 01/07/25 at 2:30 pm, LVN C said that the incident occurred as she reported in the incident and accident report. LVC C said she was immediately summoned to Resident #1's bedside and started notification and an investigation. LVN C said CNA A become nervous when Resident #1 confronted CNA A about the cash app being accessed and CNA A left the facility when the investigation started. LVN C shared screen shots of the cash transaction of $106.00 and refund that indicated a person by the first name of CNA A had made the transaction. Administrator not available for interview at time of investigation. Phone call attempted, no return call. Interviewed attempted by phone for CNA A with messages left with no return phone call. Record Review of a police report #2400014617 indicated: Public narrative, Nurse cash app's herself money from residents cash app without consent . Officer was at facility on 05/10/24 at 7:16 p.m. Officer obtained consent from Resident #1 to view cash app statements. The officer observed Resident #1 to receive a refund for $106.00 from CNA A. Resident #1 said that when she found the money missing, she confronted CNA A. Resident #1 said that CNA A became nervous and advised she had to leave. Resident #1 said that she received a refund from CNA A through her cash app. CNA A had already left the scene prior to arrival. Resident #1 wished to pursue charges on scene while speaking with officer. Case referred for processing. Review of Employee file revealed CNA A held a current Texas Nurse Aide Certification, was hired on 04/23/24 completed orientation to include abuse, neglect, exploitation, and misappropriation, maintaining resident rights including dignity, mail, visitors, personal property and telephone. Background Profile 04/09/24 reflected clear public records; Misconduct Registry 04/11/24 reflected no results (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 2 of 5 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 01/07/2025 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 found; Criminal History Conviction search reflected no search results found and a copy of the employee termination, completed with CNA A per phone call and signed by DON post complete investigation on 05/16/2024. During interviews with staff present on morning and evening shifts from 01/07/2025 10:00 am to 5:00 p.m. to 01/08/2025 9:00 a.m. to 3:00 p.m. revealed the staff were able to identify that the abuse coordinator was the Administrator. The staff said that they would report any abuse, neglect, exploitation, or misappropriation immediately, and had been trained on exploitation and misappropriation. A record review of the facility's Abuse, Neglect and Exploitation Policy revised April 2021 reflected that was the policy of the facility to 1. Protect resident from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to .a. facility staff. 2. Develop and implement policies and protocols to prevent and identify . c. theft, exploitation, or misappropriation of resident property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 3 of 5 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 01/07/2025 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 16 residents (Resident #2) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA D and CNA E wore appropriate PPE for enhanced barrier precautions when providing catheter care to Resident #2 on 1/6/25. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: Record review of a facility face sheet dated 1/6/25 for Resident #2 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of myocardial infarction (heart attack). Record review of a 5-day MDS assessment dated [DATE] for Resident #2 indicated that she had a BIMS score of 13, which indicated that she had intact cognition. She required partial/moderate assistance with toileting hygiene. She had an indwelling catheter and was occasionally incontinent of bowels. Record review of a comprehensive care plan dated 10/3/24 for Resident #2 indicated that she required enhanced barrier precautions due to having a urinary catheter and a chronic wound. Record review of a physician's order summary report dated 1/6/25 for Resident #2 indicated that she had an order to implement enhanced barrier precautions. During an observation and interview on 1/6/25 at 1:30 pm Resident #2 was observed in her room sitting up in a wheelchair. She was observed to have a foley catheter (an indwelling urinary drainage tube to drain urine from the bladder to a bag on the outside of the body). She said that staff do not wear gowns when providing personal care to her. She said she did not know they were supposed to do that. No signage indicating EBP was observed. No PPE box was observed inside or outside the room. During an observation on 1/6/25 at 3:40 pm CNA D and CNA E were observed to provide catheter care to Resident #2 in her room without donning gowns as required for enhanced barrier precautions. During a joint interview on 1/6/25 at 4:00 pm CNA D and CNA E both said they were not aware that Resident #2 required enhanced barrier precautions. They both said they had not received training on enhanced barrier precautions or when to use it. During an interview on 1/6/25 at 4:20 pm Regional Nurse Consultant said enhanced barrier precautions should be used on any resident that had an indwelling medical device such as a foley catheter, a chronic wound, and certain infectious organisms. She said Resident #2 required enhanced barrier precautions due to having a foley catheter and a chronic wound. During a joint interview on 1/6/25 at 1:45 pm IP, Regional Nurse Consultant, and DON all said they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 4 of 5 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 01/07/2025 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 expected staff to follow proper infection control protocol with regards to enhanced barrier precautions. DON said they had already begun to in-service staff and would continue to do so to ensure compliance. DON said Resident #2 must have just gotten missed being placed on EBP when she returned from the hospital in December. All said residents who require enhanced barrier precautions could be at risk for increased infections if protocol is not followed. Residents Affected - Few Record review of a facility Annual In-Service Packet dated 9/30/24 for CNA D indicated that she had received training on enhanced barrier precautions on 9/30/24. Record review of a facility Annual In-Service Packet dated 9/30/24 for CNA E indicated that she had received training on enhanced barrier precautions on 9/30/24. Record review of a facility policy titled Enhanced Barrier Precautions dated March 2024 read: .EBP is indicated for residents with any of the following: .Chronic wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers) and/or indwelling medical devices (devices fully embedded in the body, i.e., central lines, hemodialysis catheters, urinary catheters, feeding tubes and tracheostomy tubes) even if the resident is not known to be infected or colonized with a CDC-targeted MDRO . .EBP will be used when performing the following high-contact resident care activities: .providing hygiene .changing briefs or assisting with toileting .device care or use: central line, urinary catheter, feeding tube, tracheostomy . .Residents who are on EBP will have signage placed outside their room to alert staff of those residents who require the use of EBP prior to providing high-contact care activities . and; .The PPE cart will be placed directly inside the resident's room or immediately outside the room with gown and gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675519 If continuation sheet Page 5 of 5