Cycle 1
Health 2025-04-23 · Fire 2025-04-23
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lufkin, TX
Larkspur
4-star overall rating with 4-star inspections with $30,928 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
201 South John Redditt Drive, Lufkin, TX
(936) 632-3346
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
1995-07-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,582
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.18% · Performance 23.41% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.68% · Performance 8.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.28
Performance 58.43% · Measure score 1.28 · Achievement 1.28 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.11
Baseline 2.92 hours · Performance 3.09 hours · Measure score 0.11 · Achievement 0 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 11.19% · Lower 95% interval 7.37% |
| Discharge to community | 60.68% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 138 · Observed rate 55.8% · Lower 95% interval 53.01% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.96% |
95.27%
0.7 pts better
|
Numerator 95 · Denominator 99 |
| Falls with major injury | 1.01% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 99 |
| Discharge self-care score | 40.79% |
53.69%
12.9 pts worse
|
Numerator 31 · Denominator 76 |
| Discharge mobility score | 39.47% |
50.94%
11.5 pts worse
|
Numerator 30 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 1.01% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 99 · Adjusted rate 1.09% |
| Healthcare-associated infections requiring hospitalization | 8% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 8.89% · Lower 95% interval 5.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 13.77% |
42%
28.2 pts worse
|
Numerator 23 · Denominator 167 |
| Discharge function score | 56.58% |
56.45%
0.1 pts better
|
Numerator 43 · Denominator 76 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 75 · Denominator 75 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.41% |
25.2%
17.8 pts worse
|
Numerator 4 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.1
1.6 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.2% · Q3 3.3% · Q4 3.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
2.7%
3.2 pts worse
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.6% · Q3 5.5% · Q4 7.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.3%
1.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 1.9% · Q4 3.9% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
18.9%
7 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 25.0% · Q3 22.2% · Q4 25.0% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
10.8%
1.4 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 8.1% · Q3 9.3% · Q4 7.9% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.0% |
15.4%
15.4 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.9% |
16.1%
14.2 pts better
|
14.9%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 1.9% · Q4 2.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.0% |
15.0%
7 pts better
|
19.8%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 10.7% · Q3 3.5% · Q4 8.8% · 4Q avg 8.0% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.2%
1.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.7% · Q4 5.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
89.7%
0.5 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 96.2% · Q3 93.0% · Q4 74.0% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.8% |
12.0%
4.8 pts worse
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 17.9% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
88.0%
8.2 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.8% |
25.9%
4.9 pts worse
|
23.9%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.8% · Observed 32.6% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-06 · Fire 2024-03-06
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-02-08 · Fire 2023-02-08
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2025-04-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-08
F · Potential for more than minimal harm
2024-03-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-12-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-04-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-04-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-04-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-04-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-01-07
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-10
D · Potential for more than minimal harm
2025-01-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-08
J · Immediate jeopardy
2024-06-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-08
F · Potential for more than minimal harm
2024-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-05
J · Immediate jeopardy
2024-02-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-02-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-02-08
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-07
Penalties and ownership
What sits behind the stars
$17,068
2024-06-25
Fine
Fine · fine $17,068
Fine
$13,860
2024-02-12
Fine
Fine · fine $13,860
Fine
Ownership
Tyler County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Cotton, Timothy
Operational/Managerial Control · Individual
Stoneleigh Health Care Center Ltd. Co
Operational/Managerial Control · Organization
Williams, Sondra
Corporate Officer · Individual
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#2
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#3
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