Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Larkspur during CMS and state inspections, most recent first.
A resident who was dependent on staff for toileting hygiene and had multiple medical conditions did not receive timely incontinent care, resulting in saturated linens, a wet gown, and macerated skin. Staff interviews confirmed that required two-hour checks and changes were not performed during the night, contrary to the resident's care plan and facility policy.
A tube of diclofenac sodium topical gel 1% was found unsecured in a resident's room, despite facility policy requiring all medications to be stored in locked compartments and no residents being authorized to self-administer. Nursing staff and the responsible party were unaware of how the medication came to be in the room, and there was no physician order for its use.
A CNA failed to change gloves and perform hand hygiene between dirty and clean tasks while providing incontinent care to a resident with multiple comorbidities, and placed clean items on soiled linens, contrary to facility infection control policy. Interviews confirmed staff awareness of proper protocols, but the required procedures were not followed during the observed care episode.
Two residents who required staff assistance with ADLs were observed with long or dirty fingernails over several days, despite care plans and facility policy requiring regular cleaning and trimming. One resident, with parkinsonism and heart failure, had long nails with a yellow-brown substance, while another, dependent due to hemiplegia, had dirty nails with a black substance. Staff interviews revealed inconsistent nail care practices and lack of documentation regarding refusals or completion of nail care.
A resident who was dependent for all transfers was observed using a mechanical lift sling with faded straps and an illegible care tag. Additional slings with similar issues were found in the laundry area, and staff interviews revealed inconsistent training and improper laundering practices, including the use of bleach and medium heat. Facility policy and manufacturer instructions required removal of such slings, but they continued to be used due to lack of staff awareness and adherence to guidelines.
Expired albuterol and ipratropium/albuterol nebulizer medications were found in a medication room, including for two residents with respiratory and neurological conditions and for a discharged resident. The medications remained in storage despite being expired and, in some cases, without active physician orders. Staff interviews revealed that daily and weekly checks for expired medications were expected but not consistently performed, resulting in the oversight.
A syringe of normal saline and a syringe of heparin were found left on a bedside table in an unoccupied room after a resident was discharged to the hospital. Staff interviews confirmed that these medications should have been stored securely in the medication room or cart, in accordance with facility policy, and not left unattended in a resident room.
A CNA entered a resident's room who was on contact isolation for a urinary tract infection without wearing required PPE, handled items in the room, and failed to perform hand hygiene upon exit. The CNA admitted to being aware of the precautions but did not follow them due to being in a hurry, despite having received training. Facility leadership confirmed staff were trained and expected to adhere to infection control protocols.
A resident at an LTC facility experienced misappropriation of funds when a CNA accessed the resident's phone and transferred $106.00 from the resident's Cash App account without consent. The incident was reported by another CNA, leading to an investigation by an LVN, who confirmed the unauthorized transaction. The resident confronted the CNA, who then left the facility. The police were notified, and the resident received a refund. The facility suspended and later terminated the CNA following the investigation.
A facility failed to maintain an effective infection control program, as staff did not use appropriate PPE during catheter care for a resident with a catheter and chronic wound. Despite training, CNAs were unaware of the need for enhanced barrier precautions (EBP), and there was no signage or PPE box present. The oversight was acknowledged by the facility's DON and Regional Nurse Consultant.
Two residents were subjected to sexual abuse by a staff member, the Floor Tech, in a LTC facility. One resident was found in bed with the Floor Tech, while another reported inappropriate touching and gestures. Both residents had cognitive impairments and were sent to the hospital for evaluation, with no physical injuries found. The facility's investigation confirmed the incidents, and the Floor Tech was arrested.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living, including toileting hygiene, did not receive timely incontinent care. The resident, who had a history of cerebral infarction, type 2 diabetes, major depressive disorder, and hypertension, was observed on the morning of 10/29/2025 with saturated linens, a wet gown, and macerated skin on her buttocks. The care plan required staff to check and assist the resident every two hours and clean the perineal area after each incontinence episode. However, the resident reported not being changed since the previous night, and staff confirmed that the resident had not received care during the night shift as required. Staff interviews revealed that nurse aides were expected to round every two hours to ensure residents were clean and dry, but this did not occur for the resident in question. The CNA who provided care that morning stated it was her first round with the resident and acknowledged the resident was soaking wet and had not been changed since the previous night. The DON and Administrator both confirmed that incontinent care should be performed every two hours, but were unaware that the resident had not received timely care. Facility policy also required regular perineal care to promote cleanliness and prevent infection.
Unsecured Medication Found in Resident Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls for one resident. A tube of diclofenac sodium topical gel 1% was found unsecured on a desk in the room of a resident who had moderate cognitive impairment and no physician order for the medication. The resident was unable to recall how she obtained the gel. Interviews with medication aides and nursing staff confirmed that no residents in the facility were authorized to self-administer medications, and all medications should have been stored in medication carts or the medication room. The medication aide and RN were unaware that the resident had the topical gel in her possession, and the responsible party for the resident denied bringing any medications into the facility. Further interviews with the ADON, DON, and Administrator confirmed that facility policy required all medications to be stored securely and that no residents were permitted to self-administer. The facility's policy on medication storage, revised April 2007, stated that nursing staff were responsible for maintaining medication storage in a safe, secure, and orderly manner. The presence of the diclofenac gel in the resident's room indicated a failure to follow these procedures, as the medication was not stored in a locked compartment and was accessible to the resident.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during the provision of incontinent care to one resident. During an observed care episode, a certified nursing assistant (CNA) did not change gloves or perform hand hygiene when transitioning from dirty to clean tasks. The CNA also placed a clean brief on wet, soiled linens, contrary to infection control protocols. Both CNAs involved donned gowns and gloves as required for Enhanced Barrier Precautions, but the sequence of glove changes and hand hygiene was not followed as per facility policy. The resident involved had a history of cerebral infarction, type 2 diabetes, major depressive disorder, and hypertension, and was dependent on staff for toileting hygiene due to incontinence. The care plan required staff to check and assist the resident every two hours and to clean the perineal area after each episode of incontinence. During the observed care, the CNA performed perineal cleaning and applied barrier cream but failed to change gloves or sanitize hands between tasks, and placed clean items on soiled surfaces. Interviews with the CNA, Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator confirmed that the expected practice was to perform hand hygiene before care, between dirty and clean tasks, after glove removal, and at the end of care. The facility's policy also specified that glove use does not replace hand hygiene and that clean items should not be placed on dirty linens. The CNA acknowledged the lapse in protocol and attributed it to nervousness during observation.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically personal hygiene related to fingernail care, for two residents who were unable to perform these tasks independently. One resident, with diagnoses including parkinsonism and heart failure, required supervision or touching assistance with personal hygiene. Despite care plan interventions specifying that nail length should be checked and nails trimmed and cleaned on bath days and as necessary, this resident was observed on multiple occasions with long fingernails and a yellow-brown substance underneath. The resident reported that her nails needed to be cleaned and that she had not received nail care during her recent bed bath. Another resident, dependent on staff for personal hygiene due to hemiplegia following a stroke, was observed over several days with dirty fingernails containing a black substance. Although this resident stated a preference to clean her own nails and sometimes refused staff assistance, she also indicated she would not mind if staff cleaned her nails. Staff interviews revealed inconsistent awareness and follow-through regarding nail care responsibilities, with some staff unsure of the last time nail care was refused or performed. The care plan for this resident did not indicate any resistance to nail care. Facility policy required daily cleaning and regular trimming of nails to prevent infection, and staff interviews confirmed that nail care was expected to be performed on shower or bath days, with nurses responsible for diabetic residents. However, observations and resident interviews demonstrated that these procedures were not consistently followed, resulting in two residents having unclean and untrimmed fingernails over multiple days.
Failure to Remove Worn and Damaged Mechanical Lift Slings from Service
Penalty
Summary
The facility failed to ensure that the environment remained as free from accident hazards as possible by not removing worn and damaged mechanical lift slings from service. Observations revealed that a resident who was dependent for all transfers and required a mechanical lift was using a sling with faded straps and an illegible care tag. The resident confirmed that staff used this sling for her transfers. Additional observations in the laundry area found slings with similar issues, including faded colors and illegible tags, being processed and prepared for use. Interviews with the Laundry Supervisor and Laundry Aide indicated a lack of consistent training and understanding regarding the criteria for removing slings from service. The Laundry Supervisor had not received specific training on lift sling requirements and had never removed a sling from service, while the Laundry Aide only removed slings with visible rips or holes, not recognizing faded or bleached slings as unsafe. Both staff members described laundering practices that included the use of bleach and medium heat drying, contrary to manufacturer instructions, which specifically prohibit bleaching and recommend low-temperature drying. Review of facility policy and manufacturer instructions confirmed that slings showing signs of wear, fading, or improper laundering should be immediately removed from use. Despite these guidelines, slings with faded straps and illegible tags continued to be used for resident transfers. Interviews with facility leadership, including the DON and Administrator, revealed a lack of awareness regarding manufacturer guidelines and the unsafe condition of the slings being used.
Expired Medications Not Disposed of in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not disposing of expired medications in one of its medication rooms (Bluebonnet). During a review and observation, expired medications were found for three residents, including albuterol and ipratropium/albuterol nebulizer treatments that had expired as early as October 2024 and as recently as February 2025. These medications were still present in the medication room despite being expired and, in some cases, despite the residents no longer having active orders for them or having been discharged from the facility. Record reviews indicated that two residents with significant respiratory and neurological conditions, such as cerebral infarction, hemiplegia, COPD, and pneumonia, had expired albuterol medications stored in the medication room. For one resident, there was no active physician order for the expired medication found. Another resident, who had been discharged, still had multiple boxes of expired ipratropium/albuterol in the medication room, with one box expired for several months. The facility's policy required that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, but this was not followed. Interviews with nursing staff, including an LVN, ADON, and DON, revealed that responsibility for checking for expired medications was shared among nurses, medication aides, and nurse managers, with expectations for daily and weekly checks. However, the presence of expired medications indicated that these checks were not consistently performed. Staff acknowledged that expired medications should have been discarded and that the oversight was not identified until brought to their attention during the survey.
Unsecured Medications Left in Unoccupied Room
Penalty
Summary
Surveyors observed that in one unoccupied room, a syringe of normal saline 0.9% and a syringe of heparin 500 units per 5 ml were left on a bedside table. The room's previous resident had been discharged to the hospital the prior week. Staff interviews confirmed that these medications were house stock and should not have been left unsecured in the room. The LVN assigned to the area was unsure how or why the medications were left there, but acknowledged that all medications should be stored in the medication room or cart, not at the bedside. Further interviews with the ADON, DON, and Administrator confirmed that facility policy requires all medications to be stored securely and never left in resident rooms, especially after discharge. Staff recognized that leaving medications unsecured could allow access by other residents. A review of the facility's medication storage policy indicated that all drugs and biologicals must be stored in a safe, secure, and orderly manner, and not left in resident rooms.
Failure to Follow Contact Isolation Precautions by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow contact isolation precautions for a resident who had a physician's order for contact isolation due to a urinary tract infection. The CNA entered the resident's room to set up a meal tray without wearing the required personal protective equipment (PPE), including gloves and gown, despite clear signage indicating the need for contact isolation. The CNA handled the resident's over bed table and bed remote control without PPE and left the room without performing hand hygiene. During an interview, the CNA acknowledged awareness of the isolation status and training on proper precautions but stated she was in a hurry and forgot to don PPE. The resident involved was an older female with a history of memory deficit following cerebrovascular disease, who was cognitively intact and required supervision with activities of daily living. Facility records confirmed the resident's need for contact isolation and that the CNA had received training on isolation, PPE use, and handwashing. Interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that staff were expected to follow infection control protocols and had been trained accordingly. Facility policy required staff to wear gloves and gowns when entering rooms of residents on contact precautions, especially when handling environmental surfaces or items in the resident's room.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property when a Certified Nursing Assistant (CNA) took money from the resident's Cash App account. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 14, and had been admitted to the facility with diagnoses including sepsis and atherosclerosis. The resident reported that while receiving care from the CNA, her phone was accessed, and $106.00 was transferred from her Cash App account without her consent. The incident was reported by another CNA to a Licensed Vocational Nurse (LVN), who then initiated an investigation. The LVN confirmed the unauthorized transaction and refund through the Cash App, which was linked to the CNA's first name. The police were notified, and a report was filed. The resident confronted the CNA, who became nervous and left the facility. The resident received a refund shortly after the incident and expressed satisfaction with how the facility handled the situation. The facility's investigation included notifying the appropriate state agency, suspending the CNA, and conducting resident interviews and safety surveys. The CNA was terminated following the investigation. The facility's policy on abuse, neglect, and exploitation was reviewed, which emphasized the protection of residents from misappropriation of property by staff.
Inadequate Infection Control Practices for Resident with Catheter
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by staff members during catheter care for a resident. The resident, a female with a history of myocardial infarction, was admitted with an indwelling catheter and a chronic wound, necessitating enhanced barrier precautions (EBP). However, during observations, it was noted that certified nursing assistants (CNAs) did not wear gowns as required for EBP while providing care. Additionally, there was no signage or PPE box present to indicate the need for EBP, and the resident was unaware of the requirement for staff to wear gowns during personal care. Interviews with the CNAs revealed a lack of awareness and training regarding the necessity of EBP for the resident, despite having received training on the subject in the past. The facility's policy clearly outlined the conditions under which EBP should be implemented, including for residents with indwelling medical devices and chronic wounds. The oversight in implementing EBP for the resident upon her return from the hospital was acknowledged by the facility's Director of Nursing (DON) and Regional Nurse Consultant, who recognized the potential risk of increased infections due to non-compliance with infection control protocols.
Facility Fails to Prevent Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect two residents from sexual abuse by a staff member, identified as the Floor Tech. The first incident involved a resident who was found in her room with the Floor Tech lying in bed with her. This resident, who had a history of cerebral infarction, dysphagia, and moderate cognitive impairment, was unable to provide coherent responses during an interview and did not recall the incident. The resident was non-ambulatory and required substantial assistance with activities of daily living. Despite being sent to the hospital for evaluation, no physical injuries were found. The second incident involved another resident who reported to a CNA that the Floor Tech had inappropriately touched her and made sexual gestures. This resident had vascular dementia and moderate cognitive impairment. She described the Floor Tech as having rubbed his body against her while clothed and making inappropriate comments. The resident was also sent to the hospital, where no physical injuries were noted. She later expressed feelings of anger and violation during a psychological evaluation. Both incidents were reported to the facility's administration, and the Floor Tech was removed from the resident care areas. The facility's investigation confirmed the allegations, and the police were involved, leading to the arrest of the Floor Tech. The facility's failure to prevent these incidents placed residents at risk of further abuse and psychosocial harm.
Removal Plan
- Reported to HHSC.
- Employee was removed from the patient care area until police arrived.
- Police department notified.
- Both patients were sent to the ER for evaluation and treatment.
- Abuse Questionnaires/safe surveys of interviewable patients.
- Head to toe assessments of non-interviewable patients.
- Rounds of all patients to ensure their safety.
- Request video footage from family to review incident, if available.
- Psychosocial assessments completed.
- Referrals to psych service.
- Abuse Questionnaire for staff.
- Audit of employee background checks.
- Interview/statements from staff members. Note any history of unusual behaviors with the suspected employee.
- Sex registry check on suspect.
- Grievances.
- Completion of Accident/Incident Reports.
- Review of employee's schedule and time punch detail.
- Review of employee file and prior background check.
- In-service on abuse and identify sexual abuse.
- In-service Abuse Prohibition Protocol.
- In-service on Media Policy and HIPAA.
- Notification to RPs.
- Physician Notification.
- Notification to the Ombudsman.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lufkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kennedy Health & Rehab | 0.5 mi | ★★★★★ | 14 | 7 |
| Castle Pines Health And Rehabilitation | 0.8 mi | ★★★★★ | 1 | 1 |
| Parkwood In The Pines | 1 mi | ★★★★★ | 11 | 0 |
| Pinecrest Retirement Community | 2.6 mi | ★★★★★ | 2 | 0 |
| Southland Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 9 | 0 |
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