Carillon Inc

establish a grievance policy and make prompt efforts to resolve grievances.

file a grievance or complaint available to the residents for 10 of 10 confidential residents reviewed for

prominent locations, the Grievance Procedure, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance.

This failure could place residents at risk of unresolved grievances and decreased quality of life.

Findings include: In Interviews at an undisclosed date and time, 10 of 10 confidential residents stated they did not know they could file a Grievance anonymously; they did not recall the Grievance procedure being discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations.

The residents stated they did not know where to acquire a grievance form, who to turn the form into, and what happened once a grievance was filed.

The Residents did not know they had the right to receive a written decision once their grievance was resolved.

Observations of prominent postings on 06/16/2026 at 4:25pm; the facility did not include instructions regarding the Grievance procedure with the prominent postings.

Interview with the ADM on 06/17/2026 at 10:15am; the ADM stated he was the Grievance Officer for the facility.

The ADM stated the Grievance form was available on a shelf on the wall by the downstairs elevator; he stated the forms can also be obtained by any staff member.

The ADM stated he assigned grievances to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant.

The resolution was documented on the Grievance form, and the completed form was submitted to the ADM for review.

The ADM stated completed Grievance forms were kept in a notebook for 3 plus years.

The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance and he discussed Grievances in daily IDT meetings.

The ADM stated he would also meet with the complainant to ensure they were satisfied with the resolution, if needed.

The ADM stated he and the management team were responsible for ensuring staff were trained on the Grievance process.

The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council; the ADM agreed the availability of the Grievance forms, the Grievance procedure, and procedure for submitting a Grievance form anonymously should be explained to Residents at admission and continually discussed in monthly Resident Council meetings.

The ADM stated the potential negative outcome for Residents not being educated on the Grievance process was unsatisfied Residents.

Record

Review of the Grievance Policy last updated in January 2024 reflected: Policy Statement:It is a policy to thoroughly investigate all residents and families' grievances/complaints.

Resolution will be documented on the facility grievance/concern form.

Policy Interpretation and Implementation: Federal and state law guarantee the right to submit a formal grievance to all residents of this facility.

Grievance forms will be kept in the foyer on each floor of the facility.Any staff member may assist a family member or resident with completing the form.Completed forms will be given to the social services department.

Appropriate staff member will complete the investigations.After the investigation is completed it will be documented on the grievance form; the completed form will be submitted to the ADM.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

675997 06/17/2026

Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416

Timeframes for completion and submission of assessments is based on the current requirements

within 14 days after the MDS completion date (Z0500B + 14 calendar days) .

675997 06/17/2026

Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416

During an interview on 06/17/2026 at 11:33 AM, the ADM stated he was not aware that physicians orders for medications had not been accurately followed until after the medication observation was conducted. He stated nursing administration was responsible to assure staff were administering medications accurately and according to physicians orders. He stated the system to monitor accuracy of medication administration was by audits conducted by nursing administration, pharmacy consultants, and the nurse consultant.

The ADM stated all nursing staff had been trained on accurate medication administration and received continuing education at the facility level.

The ADM stated a potential negative outcome for failure to follow physicians orders during medication administration was hospitalization or other serious injuries or reactions from medications.

Record review of the facility policy titled Administering Medications (Revised April 2019) revealed: Policy headingMedications are administered in a safe and timely manner, and as prescribed.

Policy Interpretation and Implementation.4.

Medications are administered in accordance with prescriber orders . 11. the following information is checked/verified for each resident prior to administering medications:.b.

Vital signs, if necessary.

During an interview on 06/17/2026 at 12:01 p.m., the ADM stated, It

residents expired food items which could lead to food borne illness. He stated, at this point, he

have been labeled and dated. He further stated that, the kitchen staff have been trained and were continuously re-educated throughout the year and I have not seen the policy(s).

When asked about the open garbage can, the ADM stated, if not in use, then it should be covered, I can't tell you why the can was not covered, that is something you should speak to with the DM and such would cause potential cross contamination. He further stated that all kitchen staff should have their hair restraint while prepping, and there was no reason why DC shouldn't have been wearing the hair restraint.

Record review of the facility's policy and procedure titled, Food receiving and Storage, undated, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.

Policy Interpretation and Implementation: Refrigerated/Frozen StorageAll foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).

Record review of the facility policy and procedure titled, Garbage Can, undated, reflected the following: Purpose: Properly dispose of garbage and clean cans in order to comply with sanitation standards.

Procedure: Place new garbage bags in can and replace lid.

Place garbage cans in proper place.

Record review of the facility policy and procedure titled, Employees - Personal Cleanliness, undated, reflected the following: Purpose: Personal cleanliness is extremely important and the responsibility of each Food & Beverage Department staff member.

Bacteria can be present on hands, skin, breath, and hair; therefore, proper cleanliness practices are vital link in the prevention of food-borne illnesses.

Procedure: Food employees in food preparation areas and during food preparation should wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

675997 06/17/2026

Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416

Observation on 06/15/2026 at 10:01 a.m., revealed the facility's dumpster area, which was in the docking area behind the kitchen had commercial-size dumpsters (#1 and #2), with open doors.

Further observations revealed improperly trashed iron bars (x5) and black trash bags (x2) on the ground behind both dumpsters (#1 and #2).

During an interview on 06/17/2026 at 11:47 a.m., the MM stated that anyone who used the dumpster was responsible for making sure the trash was thrown into the dumpster properly and doors closed. He added that anyone who used the dumpsters was responsible for monitoring the identified failures, closing the dumpster doors, trashing the iron bars/black trash bags on the ground behind the dumpsters properly. He further stated, because people don't do their job properly, they should be held accountable.

The MM stated he had not been trained on such task and have not seen any waste disposal policy. He stated that such failures could cause the spread of rodents and environmental pollution.

During an interview on 06/17/2026 at 12:01 p.m., the ADM stated, typically, I would have that carried out by the MM, it is an IDT (Inter disciplinary team) approach to make sure that the dumpster doors were closed after trashing and garbage trashed properly. He stated, at this time, they do not have anyone assigned to monitor the mentioned or identified failures. He further stated, he cannot speak to why the iron bars/black trash bags on the ground behind the dumpster were not properly trashed and dumpster doors not closed, that is due to lack of coordination.

The ADM added that the staff have not been trained on such task at this time and have not come across the waste disposal policy. He further stated, staff need to have proper hand hygiene after disposing the trash before returning to resident care areas, that would be a potential infection risk.

Record review of the facility policy and procedure titled, Dumpster Use and Waste Disposal Policy, undated, reflected the following: Policy Statement: All waste shall be disposed of in designated dumpsters.

Dumpster areas must remain clean and free of debris, pests, and safety hazards.

Dumpster lids and exterior doors leading to dumpster areas shall remain closed and secured when not in use.

Procedures: 1.

Waste Disposal1.

Place all trash directly into designated dumpsters.2.

Do not leave waste on the ground or beside dumpsters.3.

Secure trash bags before disposal.5.

Dispose of regulated or hazardous waste according to facility policy and applicable regulations.2.

Dumpster and Door Requirements1.

Dumpster lids and access doors must remain closed when not in use.2.

Exterior doors to dumpster areas shall not be propped open.3.

Dumpster Area Cleanliness1.

Keep the dumpster area clean and free of trash, spills, odors, pests, and safety hazards.2.

Clean the surrounding area as needed to maintain sanitary conditions.Monitoring and Compliance1.

Facility staff shall routinely inspect dumpster areas.

675997 06/17/2026

Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416

discretion of the facility policy.

She stated the facility policy for EBP was reviewed annually.

Record

spread of multi-drug-resistant organisms (MDROs) to residents.Policy Interpretation and

control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents.2.

EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.a. gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b.

Personal protective equipment (PPE) is changed before caring for another resident .3. EBPs are indicated for residents with:a.

Foley cathetersb.

Complex/infected woundsc. PICC/CVL linesd.

Drains (JP, pleurex, etc.) .8.

Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.9. PPE is available near or outside the resident rooms.

Record review facility sign titled Enhanced Barrier Precautions, undated revealed the following: .Providers and staff must also:Wear gloves and gown for the following High-Contact Resident Care Activities.Wound Care: any skin opening requiring a dressing.

675997 06/17/2026

Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416