Health inspection·February 9, 2023

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on 02/09/23 at 01:40 PM, she stated the MDS coordinators complete the MDS assessments. She stated that quarterly assessment should be done once a once a quarter. She stated that she is not sure why the MDS and discharge assessment were not done. She stated that they were in between staff at that time those were missed. She stated the MDS nurse RN A started mid-November. She stated that the potential negative outcome for missed MDS or discharge assessments could be they don't have a true picture of the residents in the building. And if you don't have an accurate assessment, you don't have an accurate care plan. During an interview with the admin on 02/09/23 at 02:00 PM, she stated the MDS coordinators RN A and LVN D are responsible for completing all MDS assessments. She stated that she is not sure why the quarterly MDS was missed and stated the MDS coordinator RN A started early November. She stated the potential negative outcome for missed MDS assessments or late submissions is in accurate data sent to CMS. Record review of facility policy dated July 2017, titled MDS Completion and Submission Timeframes revealed: Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission time frames. Policy Interpretation and Implementation: 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of the RAI manual dated October 2019 indicated quarterly assessments are completed by calculating from the ARD (assessment reference date) of the previous assessment plus 92 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 2 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an encoded, accurate, and complete MDS quarterly and Discharge assessments was electronically transmitted to the CMS System within 14 days of assessment for 3 of 27 resident reviewed for MDS assessments. (Residents #35, #57 and #100) Residents Affected - Few The facility did not ensure the Quarterly MDS assessment was transmitted as required for Resident #57. The facility did not ensure the Discharge MDS assessment was transmitted as required for Residents #35 and #100. This failure could place the residents at risk for MDS assessments not being transmitted and not receiving care and services as needed. Findings included: Resident #35 Record review of admission record for Resident #35 dated 02/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 08/23/22 with diagnosies to include spinal stenosis (narrowing of the spinal cord), intestinal obstruction, hypertension (high blood pressure), hyperlipidemia (high lipids), depression and weakness. Record review of the discharge assessment for Resident #35 dated 08/24/22 revealed Section Z titled Assessment Administration revealed no RN signature and no date RN assessment coordinator signed assessment as complete. Record review of Resident #35's electronic health record MDS tab revealed Resident #35 DC home on 8/23/22 created on 8/24/22 and no signature. Resident #57 Record review of admission record for Resident #57 dated 02/10/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include chronic obstructive pulmonary disease (lung disease), depression, edema (swelling), and hypertension (high blood pressure). Record review of the quarterly assessment for Resident #57 dated 11/17/22 revealed Section Z titled Assessment Administration revealed RN signature and 11/18/22 date completed. Record review of Resident #57's electronic health record MDS tab revealed Resident #57 quarterly assessment dated [DATE], created on 11/03/22 and no e-signed. Resident #100 Record review of admission record for Resident #100 dated 02/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/26/22 with diagnosis to include heart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 3 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0640 failure, diabetes (high blood sugar), hypertension (high blood pressure) and anxiety. Level of Harm - Minimal harm or potential for actual harm Record review of the discharge assessment for Resident #57 dated 09/26/22 Section Z titled Assessment Administration revealed no RN signature and no date RN assessment coordinator signed assessment as complete. Residents Affected - Few Record review of Resident #100's electronic health record MDS tab revealed Resident #100 discharge assessment dated [DATE], created on 09/28/22 and no e-signed. During an interview with LVN A on 02/09/23 at 01:30 PM she stated Resident #100's discharge assessment was completed but not signed or transmitted. She stated Resident #57 was still a current resident at the facility and her quarterly MDS dated [DATE] was completed but not signed or transmitted. She stated Resident #35 discharge assessment was completed but not signed or transmitted. She stated she is responsible for completing skilled residents MDS assessments and RN A responsible for completing long-term care residents MDS assessments. She stated that she completes the MDS assessments and then sends RN A an email letting her know they need to be signed by the RN and once she reviews the assessments and signs them, she will send her back another email to let her know they are ready. Once the MDS assessments are complete she initiates the batch and sends the batch to CMS. She stated that the quarterly and discharge assessments should be transmitted to CMS 14 days after RN signature. She stated the reason the discharge assessments and the quarterly assessment were not transmitted was an oversight and missing RN signatures. She stated she may have forgot to send the email to the RN. She stated the potential negative outcome of a missed MDS assessment could be something missing from the care plan like therapy or depression screening that might need medication changes. She said that discharge assessments not being complete does not give accurate information to CMS, which could affect quality measures. She stated she is not aware of any system in place to monitor completion of MDS assessments. During an interview with RN A on 02/09/23 at 01:48 PM, she stated She stated Resident #100 discharge assessment was completed but not signed or transmitted but this was before her time. She stated Resident #57 was still a current resident at the facility and her quarterly MDS dated [DATE] was completed but not signed or transmitted and this was before her time. She stated Resident #35 discharge assessment was completed but not signed or transmitted and stated this was before her time. She stated she is responsible for completing MDS assessments for long-term care residents and LVN D is responsible for completing MDS assessments for skilled residents. She stated all MDS assessments come to her for completion and once they are completed, she signs off on them and notifies LVN D. She stated LVN D creates the batch and sends the batch to CMS. She stated that discharge assessment should be done day of discharge and transmitted within seven days. She stated she was not currently employed at the time the MDS assessments were missed and she is not sure why they were not done. She stated that she started mid-November as the MDS coordinator RN. She stated the potential negative outcome for incomplete or missed MDS assessments could be missed concerns from not looking at the bigger picture and it can also affect the reimbursement for Medicare residents. During an interview with DON on 02/09/23 at 01:40 PM, she stated the MDS coordinators complete the MDS assessments. She stated the quarterly and discharge assessments should be transmitted within 14 Ddays. She stated that she is not sure why the MDS and discharge assessment was not done or why they were not transmitted. She stated that they were in between staff at that time those assessments were missed. She stated that MDS RN A started mid-November. She stated that the potential negative outcome for missed MDS or discharge assessments could be they don't have a true picture of the residents in the building and if you don't have an accurate assessment, you don't have an accurate care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 4 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0640 Level of Harm - Minimal harm or potential for actual harm During an interview with Admin on 02/09/23 at 02:00 PM, she stated MDS coordinator RN A and LVN D responsible for completing all MDS assessments and transmission of those assessments. She stated that she is not sure why the MDS is were missed and stated MDS coordinator RN A started early November. She stated the potential negative outcome for missed MDS assessments or late submissions is in accurate data sent to CMS. Residents Affected - Few Record review of policy titled Electronic Transmission of the MDS revised March 2004 provided by the facility revealed: Policy statement: All MDS admission assessments (e.g. annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into out facility's computer MDS informational system and transmitted to the State database in accordance with current OBRA regulations governing the transmission of MDS data. Policy Interpretation and Implementation: 6. MDS electronic submissions shall be conducted in accordance with current OBRA regulations governing the transmission of such data. Record review RAI OBRA Page 2-17 dated October 2019 provided by the facility revealed quarterly and discharge assessment transmission date no later than 14 calendar days after MDS completion date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 5 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0642 Ensure a qualified health professional conducts resident assessments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure each individual who completed a portion of the assessment signed and certified the accuracy of that portion of the assessment for 2 of 27 residents (Resident #35 and #100) reviewed for coordination and certification, in that: Residents Affected - Few Resident #35 and #100's discharge MDS assessment was not signed by a RN. This deficient practice could place residents whose MDS assessments were not transmitted or completed at-risk of not having their assessments transmitted timely. The findings were: Resident #35 Record review of admission record for Resident #35 dated 02/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 08/23/22 with diagnosis to include spinal stenosis (narrowing of the spinal cord), intestinal obstruction, hypertension (high blood pressure), hyperlipidemia (high lipids), depression and weakness. Record review of the discharge assessment for Resident #35 dated 08/24/22 revealed Section Z titled Assessment Administration revealed no RN signature and no date RN assessment coordinator signed assessment as complete. Record review of Resident #35's electronic health record MDS tab revealed Resident #35 DC home on 8/23/22 created on 8/24/22 and no e-signed. Resident #100 Record review of admission record for Resident #100 dated 02/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/26/22 with diagnosis to include heart failure, diabetes (high blood sugar), hypertension (high blood pressure) and anxiety. Record review of the discharge assessment for Resident #57 dated 09/26/22 Section Z titled Assessment Administration revealed no RN signature and no date RN assessment coordinator signed assessment as complete. Record review of Resident #100's electronic health record MDS tab revealed Resident #100 discharge assessment dated [DATE], created on 09/28/22 and no e-signed. During an interview with LVN D on 02/09/23 at 01:30 PM, she stated Resident #35 discharge assessment was completed but not signed by the RN. She stated Resident #100 discharge assessment was completed but not signed. She stated once the assessment is completed, she sends RN A an email to notify her the assessment is complete. She reviews the assessment and sign them. She stated that she is responsible for skilled residents MDS assessments and RN A is responsible for long-term care residents MDS assessments. She stated a discharge assessment should be completed 14 days after discharge. She stated the discharge assessment was an oversight. She stated the potential negative outcome of a missed discharge assessment could be it does not give accurate information to CMS, which could affect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 6 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0642 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few quality measures. She stated she is not aware of any system in place to monitor completion of MDS assessments. During an interview with RN A on 02/09/23 at 01:48 PM, she stated Residents #35 and #100 discharge assessment was completed but not signed by the RN. She stated these missed discharge assessments were before her time. States she is responsible for completing MDS assessments for long-term care residents and LVN D is responsible for completing MDS assessments for skilled residents. She stated that all MDS must come to her for completion and once they're completed, she signs off on them. She stated that discharge MDS assessment should be done the day of discharge. She stated that she was not currently employed at the time the MDS assessments were missed and she is not sure why they were not done. She stated that she started mid-November as the MDS coordinator RN. She stated the potential negative outcome for incomplete or missed MDS assessment is it could affect the reimbursement for Medicare residents. During an interview with the DON on 02/09/23 at 01:40 PM, she stated the MDS coordinators complete the MDS assessments. She stated the discharge assessments should be done on day of discharge. She stated that she is not sure why the MDS and discharge assessment was not done. She stated that they were in between staff at that time those were missed. She stated that the potential negative outcome for missed MDS or discharge assessments could be they don't have a true picture of the residents in the building. During an interview with the Admin on 02/09/23 at 02:00 PM she stated the MDS coordinator RN A and LVN D are responsible for completing all MDS assessments. She stated she is not sure why the MDS assessments were missed. She stated the potential negative outcome for missed MDS assessments or late submissions is in accurate data to CMS. Record review of CMS RAI User manual provided by facility, dated 10/2019, revealed the RN assessment coordinator's signature must be done 14 calendar days after the Assessment Reference Date or discharge date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 7 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the comprehensive care plan was individualized for resident care needs for 4 of 21 residents reviewed for care plans. (Resident #2, #10, #17, and #104) in that, - Residents #2 and #17 had a DNR care plans; however, the nursing interventions for the DNR care plan were for a Full Code care plan. -Resident #10's care plan was missing an care area for dental -Resident #104's care plan included a care area for full code when Resident #104 is a DNR Findings include: Resident #2 Record Rreview of Resident #2's face sheet dated 09/13/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Brain Hemorrhage, Diabetes, Repeated Fall, UTI, abdominal pain, Hypothyroidism, anxiety, insomnia. Record Rreview of Resident #2's comprehensive MDS dated [DATE] revealed the following: Section C - Cognitive Patterns - C0500. BIMS Summary Score= 6 which was rated as severely cognitively impaired. Section O Special Treatments, Procedures, and Programs Summary: K. Hospice Care Record review of Resident #2's care plan, dated 9/22/22, revealed under Advanced Directives Medical Power of Attorney, DPOA, Directives to Physicians, DO NOT RESUSCITATE, Hospice. Goal: Resident #2 will have request honored during facility stay. Interventions listed for DNR status include: Family/MD will be notified of Change in Condition Disciplines: Skilled Nursing If Code Status changes, the clinical record will be updated to reflect change. Nursing Staff will provide chest compressions/respirations when the residents heart stops and call ambulance to transfer to hospital. Resident #10 Record review of Resident #10's admission record dated 02/08/23 revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include hypertension (high blood pressure), urinary tract infection, weakness, and heart disease. Record review of Resident #10's Annual (Comprehensive) Minimum Data Set (MDS), dated [DATE], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 8 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0656 revealed: Level of Harm - Minimal harm or potential for actual harm Section C Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. Residents Affected - Some Section V titled Care Area Assessment (CAA) Summary revealed dental triggered to be care planned. Section L titled Oral/Dental Status revealed Resident #10 had obvious or likely cavity or broken natural teeth. Record review of Resident #10's care plan, dated 01/06/23, revealed no care plan for dental. Resident #17 Record review of Resident #17's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include sudden loss of consciousness, anxiety, malnutrition, insomnia, difficulty walking, pressure ulcer, dementia, hypotension, hypothyroidism, and insomnia. Record review of Resident #17's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 9, which was rated as moderately cognitively impaired (alert and oriented x time, place, and person). Section O Special Treatments, Procedures, and Programs Summary: K. Hospice Care Record review of Resident #17's care plan, dated 01/3/23, revealed under Advanced Directives Medical Power of Attorney, DPOA, Directives to Physicians, DO NOT RESUSCITATE, Hospice. Goal: Resident #17will have request honored during facility stay. Interventions listed for DNR status include: Family/MD will be notified of Change in Condition Disciplines: Skilled Nursing If Code Status changes, the clinical record will be updated to reflect change. Nursing Staff will provide chest compressions/respirations when the residents heart stops and call ambulance to transfer to hospital. Resident #104 Record review of Resident #104's admission record, dated 02/07/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include: celiac disease (intestines disease), weakness, and dementia (memory problems). Record review of Resident #104's active physician orders, dated 02/07/23, revealed an order: DO NOT RESUSCITATE with a start date of 09/25/22. Record review of Resident #104's annual comprehensive care plan, dated 02/07/23, revealed Resident #104 had a care area for FULL CODE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 9 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/09/23 at 10:00 AM, LVN D confirmed Resident's #2 and #17 had a full code care area care plan with interventions for a full code. LVN D confirmed Resident #10 was missing a care are in her care plan for dental and LVN D confirmed Resident #104 had a care plan for full code when Resident #104 is a DNR. LVN D stated it was her oversight on these areas missing or being incorrect. LVN D stated she is trained on care plans, and she just made a mistake. LVN D stated care plans are reviewed in care plan meet quarterly and as needed. LVN D stated the residents were at risk of missed care areas or the nurses getting the care wrong. During an interview on 02/09/22 at 3:00 PM, the Administrator, stated she did not know why there is a discrepancy between the DNR care plans for residents #17 and #2 and the nursing interventions listed being for a Full Code care plan. ADMIN stated the MDS nurse was responsible for initiating the comprehensive care plans and any quarterly changes. ADMIN stated the IDT team completes portions of the care plan including all full code and DNR interventions. IDT is responsible for adding needs to care plans following care plan meetings, and finally MDS coordinator is responsible for checking for any missed care plan and/or mistakes. ADMIN stated care plans are developed using the triggered care areas, admission paperwork and family wishes. ADMIN stated care plans are used for staff to guide their care of residents. The ADMIN stated the potential negative outcome for a DNR resident to be care planned for full code interventions by nursing staff are the Residents' wishes may not be respected. Record review of the facility's policy titled, Resident Care Plan Policy, with a revised dated of 09/07/12, reflected the following: Purpose - To assist the resident in achieving his or her optimal level of functioning consistent with the physician's plan of medical care. Procedure - Assessment data is collected for analysis and integration to identify and prioritize each resident's care needs. Advanced directives are considered during this process FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 10 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that one of seven residents receiving psychotropic medications (Resident #47) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #47 continued to have a PRN order for Xanax 0.25mg after 14 days without an evaluation by the physician for continued treatment. This failure problem could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. The findings include: Record review of Resident #47's face sheet, dated 2/7/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: malignant neoplasm of colon (colon cancer), muscle weakness, anxiety and hypertension (high blood pressure). Record review of Resident #47's physician orders, dated 2/7/23, revealed an order for Alprazolam (Xanax) 0.25mg 1 tablet by mouth PRN every 8 hours with a start date of 7/27/22. Record review of Resident #47's comprehensive MDS, dated [DATE], revealed Section N - Medication Section N0410 - Medications Received: B - Antianxiety - Given 7 out of 7 days. Record review of Resident #47's MAR from January 2023 revealed Alprazolam 0.25mg 1 tab PO PRN was administered on 1/14/23 and on 1/25/23. Review of Resident #47's MAR from February 2023 revealed Alprazolam 0.25mg 1 tab PO PRN was administered on 2/5/23. Record review of the pharamacy consultant book revealed no pharmacy recommendations related to Resident #47's PRN Alprazolam. Interview on 2/9/23 at 8:20 AM, the DON stated the pharmacy consultants, and the nurses are responsible for ensuring PRN psychotropic medications are stopped at 14 days and re-evaluated if necessary. The DON stated the pharmacy consultant was just here a few weeks ago and she does not know how this was missed. The DON stated the resident is at risk for increased falls, being lethargic, decreased appetite and weight loss. The DON stated Resident #47 was on hospice services and that makes it trickier to manager their medications. The DON stated she knew the rule that PRN psychotropic medications are stopped at day 14 and re-evaluated, even on hospice services. Interview on 2/9/23 at 8:32 AM, the Admin stated it was the responsibility of the DON and the nurse managers to check on PRN psychotropic medications. The Admin stated she doesn't know how this failure occurred when the medications were reviewed a few weeks ago. The Admin stated that the residents were at risk of side effects related to the psychotropic PRN medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 11 of 12 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 675997 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416 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 0758 Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled, Psychoactive Medications, Consents and GDR policy, undated, reflected the following, Purpose - To ensure psychoactive medications are used appropriately, written or verbal consent is obtained prior to the administration of any psychoactive medications . Residents Affected - Few Psychoactive medication includes the following categories: .Antianxiety agents .7. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the residents for the appropriateness of that medication FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 12 of 12