Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Carillon Inc during CMS and state inspections, most recent first.
Grievance Procedure Information Not Posted or Discussed: The facility failed to make grievance/complaint filing information available to 10 of 10 residents reviewed. Residents stated they did not know they could file anonymously, did not know where to get or submit a grievance form, and were unaware of their right to a written decision. Observation showed prominent postings lacked grievance instructions, and the ADM stated he was the grievance officer and that the grievance process should have been discussed in Resident Council.
Kitchen staff failed to follow food storage and sanitation standards when unlabeled, undated food items were found in the walk-in freezer and refrigerator, an uncovered garbage can was observed next to the prep table, and a DC was not wearing a hair restraint over his mustache area. Staff interviews confirmed that labeling, dating, covering the garbage can, and wearing hair restraints were expected responsibilities, and facility policies required covered, labeled, and dated refrigerated and frozen foods as well as proper personal cleanliness in food prep areas.
Improper Dumpster Waste Disposal: The dumpster area behind the kitchen had open doors on 2 dumpsters and trash left on the ground behind them, including iron bars and black trash bags. The MM stated anyone using the dumpsters was responsible for placing trash properly and closing the doors, but he had not been trained and had not seen a waste disposal policy. The ADM stated no one was assigned to monitor the issue and staff had not been trained on the task or reviewed the facility's dumpster use and waste disposal policy.
Infection Control and EBP Not Used During Wound Care Three residents with open wounds received wound care from RNs without PPE, and there was no PPE or precaution signage outside their rooms. The nurses and leadership stated the residents were not on EBP because the wounds were not infected or were considered simple dressings, even though the facility policy required gown and glove use for wound care involving any skin opening requiring a dressing and identified complex/infected wounds as EBP indications.
Incomplete DNR Forms for Two Residents: Two residents with DNR status had incomplete DNR paperwork. One resident with CKD and severe cognitive impairment had no resident signature on the DNR form, and the physician signed on the wrong line. Another resident with Alzheimer’s disease and severe cognitive impairment had the resident signature on the proxy line, but the physician signature, date, printed name, and license number were missing. The SW and ADM verified the forms were not completed correctly.
Failure to transmit completed discharge MDS: A resident with COPD, AFib, CHF, Type II DM, and HTN had a discharge MDS marked complete, but it was not submitted to CMS within the required timeframe. Record review showed no batch was created, and interviews confirmed the discharge assessment should have been transmitted within 14 days of completion.
Medication error rate exceeded the required threshold when an RN administered Amlodipine and Losartan Potassium to a resident despite a pulse below the ordered hold parameter of 60. The resident had HTN, hypotension, Parkinsonism, and moderate cognitive impairment. The RN acknowledged the error, and the DON and ADM stated they were unaware the physician orders had not been followed until after the observation.
Twelve residents were not provided with information about their rights to file grievances, did not have access to grievance forms, and were unaware of the grievance procedure or the option to file anonymously. Grievance procedures were not posted in prominent locations, and the ADM confirmed there was no process for anonymous submission, with staff completing grievances electronically on residents' behalf.
Surveyors found that multiple kitchen refrigerators contained prepared parfaits and uncooked pasteurized eggs that were not labeled or dated, contrary to facility policy. Dietary staff confirmed that labeling and dating were not consistently performed, and there was no system to track the use-by dates for eggs once removed from their original packaging. The deficiency was identified despite staff training and regular audits.
A CNA did not sanitize her hands between glove changes while providing incontinent care to a resident with severe cognitive impairment and multiple medical conditions. The CNA acknowledged skipping the hand hygiene step, despite prior training. Facility leadership was unaware of this lapse, and facility policy requires hand hygiene after glove removal and before moving from a soiled to a clean body site.
A facility failed to ensure proper pharmaceutical services, leading to the improper storage and potential diversion of medications for a resident with severe pain. The resident, who had cancer and other conditions, was prescribed Morphine Sulfate. After the resident's discharge and subsequent death, a card of Morphine tablets and the narcotic sheet were found missing. The facility lacked a clear system for managing medications after a resident's discharge, contributing to the deficiency.
The facility failed to secure medication carts 4S1 and 4S2 on the fourth floor, leaving them unlocked and unattended. RN A, responsible for the carts, admitted to not locking them while attending to a resident, despite being trained to do so. Interviews with the Interim DON and ADM highlighted the importance of securing medication carts to prevent unauthorized access.
A facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including heart failure and severely impaired cognition. The care plan did not accurately reflect the resident's need for assistance with ADLs and nutritional needs during meals. Observations showed the resident required frequent cueing to eat, which was not documented in the care plan. Interviews with staff revealed a lack of awareness and monitoring of the care plan's accuracy, despite facility policies requiring comprehensive, updated care plans.
A resident with severe cognitive impairment and multiple medical conditions did not receive necessary assistance with eating while on in-room isolation. Despite requiring cuing assistance and being on a mechanically altered diet, the resident was not provided help during lunch and dinner, leading to inadequate food intake. A CNA assigned to the resident was not informed of her needs, highlighting a communication and training gap in the facility's procedures.
Grievance Procedure Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 10 of 10 confidential residents reviewed for grievances. During interviews, all 10 residents stated they did not know they could file a grievance anonymously, did not recall the grievance procedure being discussed in Resident Council, and had not observed a posting of the grievance procedure in prominent locations. The residents also stated they did not know where to obtain a grievance form, who to give it to, what happened after a grievance was filed, or that they had the right to receive a written decision once their grievance was resolved. Observation of prominent postings on 06/16/2026 at 4:25 PM showed the facility did not include instructions regarding the grievance procedure with the postings. During interview on 06/17/2026 at 10:15 AM, the ADM stated he was the grievance officer, that grievance forms were available on a shelf by the downstairs elevator and could also be obtained from any staff member, and that grievances were assigned to the appropriate department for resolution and documented on the grievance form. The ADM stated completed grievance forms were kept in a notebook for 3 plus years, that grievances were monitored in daily IDT meetings, and that he was not aware the grievance procedure was not being discussed in Resident Council. The grievance policy reviewed, last updated in January 2024, stated grievance forms would be kept in the foyer on each floor, any staff member could assist with completing the form, and completed forms would be given to social services.
Kitchen Food Storage and Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During a kitchen tour, surveyors observed an uncovered garbage can next to the food prepping table, and the DC was not wearing a hair restraint to cover his mustache area. Surveyors also found food items in the walk-in freezer and walk-in refrigerator that were not labeled and did not have use-by dates. In the walk-in freezer, items that resembled scones, cookie doughs, apple scones, cinnamon rolls, and white chocolate scones were stored in clear plastic bags with no labels and no use-by dates. In the walk-in refrigerator, what resembled whipped topping was also stored in a clear plastic bag with no use-by date. The EC stated that kitchen staff were responsible for labeling and dating food items, and that staff had been in a hurry and forgot to do so. The EC also stated that the garbage can should have been covered when not in use and that the DC had removed his hair restraint and forgotten to put it back on. During interviews, the DC stated he was responsible for labeling and dating food items along with other kitchen staff, and that he had forgotten to do so. He also stated he had just gotten out of the bathroom and had forgotten to use the hair restraint. The RD, DM, and ADM each stated that kitchen staff were responsible for labeling and dating food items, that the garbage can should have been covered when not in use, and that all kitchen staff should have worn hair restraints while prepping. The facility policies reviewed stated that refrigerated and frozen foods are to be covered, labeled, and dated, that garbage cans should have lids replaced, and that food employees in preparation areas should wear hair restraints and beard restraints.
Improper Dumpster Waste Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters, specifically dumpsters #1 and #2. During observation on 06/15/2026 at 10:01 a.m., the dumpster area behind the kitchen was found with the doors to both dumpsters open, and improperly trashed iron bars (x5) and black trash bags (x2) were observed on the ground behind the dumpsters. During interviews on 06/17/2026, the MM stated that anyone who used the dumpsters was responsible for making sure trash was placed properly and the dumpster doors were closed, and he stated he had not been trained on the task and had not seen a waste disposal policy. The ADM stated that the dumpster doors should be closed after trashing and garbage should be disposed of properly, but at that time no one was assigned to monitor the identified failures. The ADM also stated staff had not been trained on the task and had not come across the waste disposal policy. The facility policy titled, Dumpster Use and Waste Disposal Policy, stated that all waste shall be disposed of in designated dumpsters, waste should not be left on the ground or beside dumpsters, and dumpster lids and exterior doors leading to dumpster areas shall remain closed and secured when not in use.
Infection Control and Enhanced Barrier Precautions Not Used During Wound Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of disease for three residents and two nurses reviewed for infection control. During wound care observations, RN B entered a resident’s room to provide care for a stage 3 pressure ulcer on the right glute without PPE, and there was no visible PPE outside the room or signage indicating transmission-based precautions. RN A also entered two other residents’ rooms without PPE while providing wound care, and there was no visible PPE outside those rooms or signage indicating transmission-based precautions. Resident #3 was a male with diagnoses including Alzheimer’s disease, prostate cancer, depression, hypertension, and peripheral vascular disease. His MDS showed severe cognitive impairment and one stage 3 pressure ulcer. His care plan and physician orders directed wound care to the right glute. During observation, RN B provided wound care without PPE. In interview, RN B stated the resident was not on enhanced barrier precautions because the wound was not infected, and she stated enhanced barrier precautions were only needed for complex wounds requiring multilayer dressings. She also stated she had been trained in enhanced barrier precautions. Resident #66 was a female with diagnoses including left femur fracture, muscle weakness, and hypertension. Her MDS showed moderate cognitive impairment and one unstageable deep tissue injury. Her care plan and physician orders directed daily wound care to the left heel. During observation, RN A provided wound care without PPE. Resident #85 was a male with diagnoses including Alzheimer’s disease, edema, diabetes, and hypertension. His MDS showed moderate cognitive impairment and risk for pressure ulcers. His care plan and physician orders directed daily wound care to bilateral lower leg wounds. During observation, RN A provided wound care without PPE. RN A stated both residents were not on enhanced barrier precautions because the wounds were not infections, and she stated she had been trained in enhanced barrier precautions. The DON, ADON, IP, and ADM all stated that the three residents were not on enhanced barrier precautions because their wounds were not infected or were simple dressings. The DON and ADON stated enhanced barrier precautions were used for residents with complex wound dressings, infections, or certain devices such as Foley catheters, PICC/CVL lines, drains, or wound vacs. The facility policy stated enhanced barrier precautions are used to reduce the spread of MDROs, are indicated for complex/infected wounds, and require signs outside the room and PPE available near or outside the room. The facility sign also stated staff must wear gloves and gown for wound care involving any skin opening requiring a dressing.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with documented DNR status had properly completed DNR forms. One resident was a male admitted with chronic kidney disease and acute cystitis with hematuria; his face sheet and physician order summary both reflected DNR status, and his MDS showed severe cognitive impairment with a BIMS score of 6. His DNR form dated 8/06/24 did not contain the resident’s signature, and the physician signed on the line intended for the resident’s signature. The second resident was a female admitted with Alzheimer’s disease and chronic kidney disease; her face sheet and physician order summary also reflected DNR status, and her MDS showed severe cognitive impairment with a BIMS score of 3. Her DNR form dated 09/25/25 had the resident’s signature on the line for a legal guardian, agent, or proxy, but the physician’s signature, date, printed name, and license number were missing. The social worker and administrator both verified the missing information and stated the forms were not valid if not completed correctly.
Failure to Transmit Completed Discharge MDS
Penalty
Summary
The facility failed to transmit a completed discharge MDS that accurately reflected Resident #40’s status within the required timeframe. Resident #40 was an [AGE]-year-old female with diagnoses including COPD, atrial fibrillation, CHF, Type II DM, and hypertension. Her record showed she was admitted to the facility on [DATE] and discharged on 01/30/2026. The electronic medical record MDS tab showed a Discharge Return Not Anticipated MDS with a status of complete, but the assessment history indicated the Discharge MDS had not been submitted and no batch had been created. The Discharge MDS for Resident #40 was documented as a completed assessment with A0310F coded as discharge assessment - return not anticipated, A2000 showing the discharge date, and A2300 showing the assessment reference date as 01/30/2026. During interview, the Clinical Reimbursement Coordinator stated the Discharge MDS should have been submitted to CMS and that all discharge MDSs should be transmitted within 14 days of completion, but this one had not been transmitted because the box remained checked. The ADM stated he was not aware the Discharge MDS had not been transmitted until the day of the interview and confirmed the 14-day submission timeframe.
Medication Given Outside Ordered Vital Sign Parameters
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors found an 8 percent medication error rate based on 2 errors out of 25 opportunities, involving 1 of 3 residents reviewed for medication administration. The deficiency centered on Resident #81, an [AGE]-year-old female admitted on 03/06/2026 with diagnoses including hypotension, candidiasis, essential primary hypertension, Parkinsonism, and cognitive communication deficit. Her quarterly MDS dated 06/09/2026 showed a BIMS score of 08, indicating moderate cognitive impairment. Resident #81 had physician orders for Amlodipine 5 mg daily and Losartan Potassium 50 mg twice daily, both with instructions to hold if pulse was less than 60. During a medication administration observation, RN A checked the resident’s vital signs before giving the medications and obtained a blood pressure of 129/65 and a pulse of 57. Despite the pulse being below the ordered parameter, RN A administered both Amlodipine and Losartan Potassium and then documented the medications as given on the MAR. During interview, RN A stated the resident should not have received either medication because the pulse was below the ordered parameter and acknowledged that she made an error and did not realize the pulse was below the set parameters at the time of administration. The DON and ADM stated they were not aware the orders had not been followed until after the observation and confirmed that nursing administration was responsible for ensuring medications were given according to physician orders. The facility policy stated medications are to be administered in accordance with prescriber orders and that vital signs are checked and verified when necessary before administration.
Failure to Provide Grievance Information and Access to Residents
Penalty
Summary
The facility failed to provide 12 out of 20 confidential residents with information regarding their rights to file grievances, including access to the grievance procedure, forms, and the ability to file grievances anonymously. During a Resident Council meeting, these residents reported that they had not been informed about the grievance process, did not know where to obtain grievance forms, were unaware of the option to file anonymously, and had not seen postings of the grievance procedure in prominent locations. All 12 residents had been living in the facility for over six months. Observations confirmed that the facility did not have grievance procedures posted in prominent areas, and grievance forms were not available for residents. An interview with the ADM revealed that there was no process for residents to submit grievances anonymously and that staff typically completed grievances electronically on behalf of residents. The ADM was unaware that the grievance procedure was not being discussed in Resident Council meetings. A review of the facility's grievance policy indicated that forms should be available on each floor and in the social service office, but this was not being followed in practice.
Failure to Label and Date Food Items in Facility Kitchens
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items stored in refrigerators across multiple kitchen units. Specifically, individual prepared and pureed parfaits, as well as uncooked pasteurized eggs stored in clear, unlabeled containers, were found without any labels or dates in several kitchen refrigerators. Dietary staff confirmed that parfaits were not dated if they were intended to be served the same day, and there was no system in place to track the preparation or expiration dates for eggs once removed from their original packaging. The facility's policy required all food items to be labeled and dated to ensure proper rotation and prevent expired food from being served. Interviews with the Dietary Manager (DM) and the Assistant Dietary Manager (ADM) revealed that all dietary staff were responsible for labeling and dating food, and that training on these procedures was provided upon hire and during monthly in-services. Despite these expectations and regular audits by the DM and the facility's registered dietician, the lack of labeling and dating persisted. The facility's written policy also specified that all food should be appropriately dated to ensure safe storage and prevent the use of expired items.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper hand hygiene protocols during incontinent care for a resident with severe cognitive impairment, Parkinson's Disease, acute respiratory failure, and incontinence of bowel and bladder. During the observed care, the CNA washed her hands and donned personal protective equipment (PPE) before beginning care, but after removing her gloves, she did not sanitize her hands before putting on a new pair of gloves and continuing with the procedure. The CNA completed the care and washed her hands only after removing her PPE at the end of the process. The CNA later acknowledged in an interview that she skipped the hand sanitizing step between glove changes, attributing it to being in a hurry, despite having received training on hand hygiene during orientation. Interviews with the administrator (ADM) and director of nursing (DON) revealed that they were not aware staff were omitting hand hygiene between glove changes during resident care. Both acknowledged that proper hand hygiene is necessary to prevent the spread of bacteria and infection, and that staff are trained and monitored for compliance. Review of the facility's hand hygiene policy confirmed that hand hygiene is required immediately after glove removal and before moving from a soiled to a clean body site on the same resident. The failure to follow these protocols was observed and confirmed through staff interviews and record review.
Failure in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in the improper storage and potential diversion of medications for a resident. The resident, a male with a history of malignant neoplasms of the spinal cord and brain, as well as benign prostatic hyperplasia, was admitted to the facility and had an active order for Morphine Sulfate to manage severe pain. The medication was to be administered every three hours as needed. However, after the resident was discharged to a hospital and subsequently passed away, it was discovered that a card of Morphine tablets and the corresponding narcotic sheet were missing from the medication cart. Interviews and record reviews revealed that the facility did not have a robust system in place to ensure the proper storage and accounting of medications, particularly after a resident's discharge or death. The missing medication was not identified until a Licensed Vocational Nurse (LVN) noticed the absence during a shift change. The LVN reported the discrepancy to the Nurse Manager, who then involved the Interim Director of Nursing (DON) and the Administrator. Despite efforts to locate the missing medication, it was not found, and the facility's procedures for removing discontinued or discharged residents' medications were unclear and inconsistently followed. The investigation highlighted several lapses in protocol, including the failure to remove the deceased resident's medications from the cart in a timely manner and the lack of a system to detect missing medications when both the narcotic sheet and medication card were absent. The facility's policy required controlled medications to be counted at the end of each shift, with discrepancies reported immediately, but this was not effectively implemented. The absence of a clear protocol for handling medications after a resident's discharge contributed to the deficiency, leaving the facility vulnerable to medication diversion and errors in medication administration.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with two medication carts, 4S1 and 4S2, on the fourth floor. On the specified date, these carts were found unattended and unlocked in the dining area, with the locks popped out. RN A, the charge nurse responsible for these carts, admitted to leaving them unlocked while she was administering a COVID test and wound care to a resident. She acknowledged her training on locking the carts when not in direct sight and recognized the potential negative outcomes of her oversight, including unauthorized access to medications. Interviews with the Interim DON and the ADM revealed that staff were trained to lock medication carts when unattended, but there was no awareness of the carts being left unlocked. Both the Interim DON and the ADM emphasized the importance of securing the carts to prevent unauthorized access and potential medication misappropriation. The facility's policy on administering medications requires that medication carts be kept closed and locked when out of sight, which was not adhered to in this instance.
Inadequate Care Plan for Resident's Nutritional and ADL Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which was consistent with the resident's rights and included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The deficiency was identified during a review of care plans for residents, where it was found that the care plan for a resident did not accurately reflect her needs for assistance with activities of daily living (ADLs) and nutritional needs, specifically during meals. The resident, who had several medical conditions including heart failure, psychotic disorder, and severely impaired cognition, required supervision and assistance during meals, which was not adequately documented in her care plan. The care plan for the resident was initiated and revised but failed to accurately capture the resident's need for cuing and supervision during meals, as indicated in her nutritional assessment. Observations during a meal showed that the resident required frequent staff cueing to eat, which was not consistently documented in her care plan. Interviews with facility staff, including the Administrator (ADM), Director of Nursing (DON), and MDS coordinator, revealed that the care plans were developed by the MDS nurse and were supposed to be monitored and updated by the interdisciplinary team. However, the DON and MDS coordinator were unaware that the care plan was not accurate or consistent with the resident's needs. The facility's policy on care plans emphasized the need for comprehensive, person-centered care plans that are updated as resident conditions change. Despite this policy, the care plan for the resident did not reflect her current needs, which could have resulted in inadequate care. The MDS coordinator acknowledged that the care plan should have been updated to reflect the resident's nutritional assessment and need for assistance during meals, highlighting a gap in the facility's care planning process.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with eating to a resident who was unable to perform activities of daily living independently. The resident, a female with severe cognitive impairment and multiple medical conditions, was on in-room isolation and required assistance with meals. On a specific day, the resident did not receive the needed help during lunch and dinner, which could lead to decreased food intake and other health issues. The resident's care plan indicated she required cuing assistance with meals and was on a mechanically altered diet. Despite this, a CNA assigned to the resident on the day in question was not informed of the resident's need for assistance with eating. The CNA delivered meals to the resident's room but did not provide the necessary support, resulting in the resident consuming very little of her meals. Interviews with facility staff revealed a lack of communication and training regarding the resident's needs. The CNA was not aware of the resident's requirements, and the facility's procedure for ensuring dependent residents receive adequate care was not effectively implemented. The facility's policy stated that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, but this was not adhered to in the case of the resident in question.
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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 Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whisperwood Nursing & Rehabilitation Center | 0.2 mi | ★★★★★ | 7 | 4 |
| The Plaza At Lubbock | 1.2 mi | ★★★★★ | 9 | 0 |
| Mi Casita Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 15 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.7 mi | ★★★★★ | 14 | 5 |
| Mesquite Post Acute Care | 1.8 mi | ★★★★★ | 11 | 0 |
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