Health inspection·May 9, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of admission record for Resident #2 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of surgical amputation, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), type 2 diabetes, vitamin deficiency, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypokalemia (low potassium), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure, low blood pressure, chronic obstructive pulmonary disease, overactive bladder, benign prostatic hyperplasia (age related prostate enlargement), with lower urinary tract symptoms. Record review of Resident #2 Annual assessment dated [DATE], revealed Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section H Bladder and Bowel: HO300 Urinary continence was coded 9, 9 - not rated, resident had a catheter (indwelling condom, urinary ostomy, or no urine output for the entire 7 days) H0400 Bowel Continence was coded 2, 2 - frequently incontinent (2 or more episodes of continent bowel incontinence, but at least one continent bowel movement). During an observation of incontinent care on 05/08/2023 at 10:17 am with CNA A and CNA B, performed incontinent care on Resident #1. CNA A and CNA B did not perform hand hygiene prior to gathering incontinent care supplies or prior to putting on gloves to provide care. CNA A and CNA B did not perform hand hygiene after providing incontinent care for Resident #1. Upon entering Resident #1's room, Resident #1 stated, I am soaked in urine. Observed CNA A and CNA B place on clean gloves without washing hands. CNA A proceeded in removing Resident #1's pants and removed Resident #1's urine-soaked brief. CNA A used one wipe and proceeded in cleaning one area with continuously wiping instead of using the one swipe per wipe method. CNA A used the wipe and started in the center groin area, wiping from the top groin area towards the shaft of the penis with several wipes and not changing to a clean wipe. CNA B removed gloves and left Resident #1's room to go get a clean brief for the resident. CNA A and CNA B failed to gather supplies prior to care. CNA B came back into resident's room with a clean brief and failed to wash hands. CNA A used a total of 2 wipes for the entire front groin area. CNA A turned Resident #1 over to the right side to clean his back area. Observed a bandage that was covering his top wound, halfway off and had been exposed in the urine-soaked brief. CNA A continued to use a clean wipe to clean the back side, starting at the center of the buttocks. CNA A discarded the wipe. CNA A used a total of 2 wipes for the backside area. CNA A did not fold the wipe to gain a clean side on either wipe. CNA A proceeded in putting the urine-soaked bandage back on the resident's wound and then stated, I am not certified to clean the wound, I will have to get a nurse. CNA A and CNA B did not wash hands for the entire incontinent care process, nor did they change gloves. CNA A and CNA B disposed of gloves at the end of providing care for Resident #1. During an observation of incontinent care on 05/08/2023 at 10:36 am with CNA A. CNA A notified Resident #2 that she would be performing catheter care. CNA A failed to wash her hands between providing incontinent care for Resident #1 and Resident #2. Observed CNA A failed to wash hands prior to providing incontinent care. CNA A placed on a new pair of gloves and was touching on the side of Resident #2's bed and bedside table prior to providing catheter care for Resident #2. CNA A got a basin full of warm water and asked Resident #2 to verify that it was not too warm. CNA A proceeded in taking off Resident #2's pants and brief to provide catheter care. CNA A dampened the clean washcloth and proceeded in wiping the catheter from the insertion site downward and then back up on the tubing toward the insertion area without using a different clean area of the washcloth. CNA A cleaned the tubing up and down a couple of times with the same washcloth. CNA A proceeded in using the washcloth and rinsing it out in the basin and cleaning Resident #2's groin area. CNA A replaced with clean brief and helped Resident #2 place back on his pants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 2 of 6 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 05/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with CNA A on 05/08/2023 at 10:52 am, CNA A stated that she had not been trained in infection control practices. CNA A stated that the form of training for other things is usually in-services, but she has not been trained in infection control practices. CNA A stated that she is not sure who is in charge of making sure that training is completed. CNA A stated that she did understand the errors of failing to wash hands before, during, and after resident care, incorrect cleaning technique for incontinent care and catheter care that was found while observations of providing incontinent care. CNA A stated that she would normally wash hands before, during, and after care. CNA A stated that she is not sure why she did not do this. CNA A stated, I guess I was a little nervous. CNA A stated that she did realize that her techniques were incorrect after she had already completed care for the resident. CNA A stated, I was just really nervous. CNA A stated that the negative potential outcome for not washing hands before, during, or after incontinent care means that she could have spread germs to other residents. CNA A stated that the only thing she could think of to do with Resident #1s open bandage being soaked in urine was to place it back on because she is not certified to clean wounds. CNA A stated that by placing the bandage back on the wound with it being soaked with urine could make the wound worse. CNA A stated that she wasn't thinking about that at the time she did that. During an interview with CNA B on 05/08/2023 at 11:13 am, CNA B stated that she has not been trained in infection control practices. CNA B stated that she did have a hand washing check off but it's been a while back (fall of 2022). CNA B stated she is not aware of who is responsible of making sure that training is completed. CNA B stated, Maybe the administrator. CNA B said that she understands the errors of failing to wash hands before, during, or after resident care, that were found during the observation of incontinent care. CNA B stated that they are supposed to wash hands before and after providing care. CNA B stated that she thought since she had gloves it would be okay to not wash hands. CNA B stated that if gloves were to break then she would have possibly exposed the resident or other residents to the spread of germs and infections. CNA B stated that she is aware that it is not hygienic practice to not wash your hands before and after providing care to residents. During an interview with the DON and the Administrator at same time on 05/09/2023 at 3:18 pm, the DON stated she trains staff to ensure they have proper techniques for incontinent care. Stated on hire there is a check off and annual skills fair. Stated they work with the agency themselves to make sure their staff has the correct credentials and then when they come to the facility, they get an orientation to the floor when they start to show where supplies are located. The DON stated she did incontinent care in-service and hand washing. The DON stated that by not washing hands you could spread germs. Administrator stated she would not expect staff to put the soiled bandage back on the wound but get the nurse and put a clean dressing on the wound. Potential outcome Infection and worsening wound. Administrator stated that she will start working on an in-service for infection control practices and hand washing. Record Review of facility provided policy, labeled, Infection Control, date not provided, revealed: Purpose: To provide guidelines for general infection control while caring for residents. General Guideline: 1). Standard precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard precautions apply to blood, body, non-intact skin, and/or mucous membranes. 3). Wash hands thoroughly with soap and water. A). Before any procedure, B0. Before resuming any procedure after an interruption, C). Anytime they become soiled with blood or body fluids, D). After changing or removing gloves or any personal protective equipment (PPE), E). Whenever in doubt, F). After completing a task or procedure. 4). Follow guidelines for the use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 3 of 6 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 05/09/2023 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 0880 of alcohol-based hand rubs. 5). Wear PPE as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. Level of Harm - Minimal harm or potential for actual harm Record Review of facility provided policy, labeled, Hand Washing, date updated on 01/27/2016, revealed: Residents Affected - Few Purpose: To prevent the spreading of germs to our residents and employees. When to Wash: 1). Before eating, 2). Before, during, and after handling or preparing food. 3). After contact with blood or body fluids (i.e. nasal secretions, saliva, urine, etc). 4). After changing a diaper/brief. 5). After touching something that culd be contaminated. 6). Before dressing a wound or giving medicine. 7). After using the restroom. Steps in Procedure: 1). Wet your hands and apply soap. 2). Rub hands together vigorously to make lather and scrub all surfaces. 3). Continue for at least 20 seconds. 4). Rinse hands well under warm running water. 5). Dry your hands using a paper towel. 6). Use your paper towel to turn off the faucet. Record Review of facility provided policy, labeled, Incontinent Care, date not provided, revealed: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps: 1. Gather equipment needed. Arrange supplies for easy access. 2. Wash and dry your hands 3. Fold the bedspread or blanket toward the foot of the bed. 4. Fold the sheet down to the lower part of the body, Cover the upper torso with a sheet. 5. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 6. Put on gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 4 of 6 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 05/09/2023 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 0880 7. Level of Harm - Minimal harm or potential for actual harm Instruct the resident to bend his or her knees and put his or her feet flat on the bed/mattress. Assist as necessary. Residents Affected - Few 10. For Male resident: A). Wash perineal area starting with urethra and working outward. 1). Retract foreskin of the uncircumcised male. 2). Wash and rinse urethral area using a circular motion. 3). Continue to was the perineal area including the penis, scrotum and inner thighs. 4). Do not use the same wipe to clean the urethra. B). Gently dry perineum following same sequences. C). Reposition foreskin of uncircumcised males. D). Instruct or assist the resident to turn on his side with the upper leg slight bent, if able. E). Wipe the rectal area thoroughly, including the area under the scrotum, the anus, and the buttock. F). Dry area thoroughly. 11. Discard disposition items into designated containers. 12. Remove gloves and discard into designated container, wash and dry your hands. 13. Reposition the bed covers, make the resident comfortable. 14. Place the call light within easy reach of the resident. 15. Clean wash basin and return to designated storage. 16. Clean the bedside table. 17. Wash and dry your hands. 18. If the resident desire, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Record Review of wound tracking log dated week ending of 04/14/2023 revealed: Resident #2 dated 04/12/2023 showed resident had 6 new wounds: coccyx stage 3 treated with calcium alginate and cover, left proximal dorsal foot (surgical) treated with calcium alginate and cover, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 5 of 6 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 05/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm left distal dorsal foot (surgical) treated with calcium alginate and cover, left lateral foot (surgical) treated with calcium alginate and cover, right 3rd toe (diabetic) treated with betadine. On 04/21/2023 shows that the wounds have not changed. On 04/28/2023 shows that 4 of the wounds have improved on the left lateral foot wound shows to have deteriorated, the right 3rd toe shows to have no change. Residents Affected - Few Record Review of wound tracking log dated week ending of 04/21/2023 revealed: Resident #1 showed resident has 4 new wounds: right ischium treated with cover with allevyn, coccyx treated with venelex, left ischium treated with venelex, left glute treated with venelex. On 04/28/2023 shows that wound on left ishium is healed, on the left glute and coccyx shows to be improved on the right ischium shows that wound has deteriorated. Record Review of CDC guidelines for hand hygiene, https://www.cdc.gov/handwashing/index.html, date not provided, revealed: Hand hygiene protects you and those receiving the care you provide. The simple act of cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics. Keeping the skin on your hands healthy and clean is a challenge that requires all healthcare personnel to be knowledgeable about how to care for their hands and when hands should be cleaned. Regular hand washing is one of the best ways to remove germs, avoid getting sick, and prevent the spread of germs to others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 6 of 6