Health inspection·January 27, 2024

F 0609 Findings Included: Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's face sheet, 01/25/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include cognitive communication deficit, dementia (loss of cognitive/memory function). Residents Affected - Some Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section J0200: Should pain Assessment be conducted? Yes All associated areas associated with pain were blank. J1700 Fall History All areas following were blank. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #1's Care plan revealed the following: Initiated 12/12/23 Revised: 12/12/23. Focus: Resident #1 had a communication problem Goal: Resident #1 will be able to make basic needs known on a daily basis Intervention: Anticipate and meet needs Initiated 12/12/2023 Revised 12/12/23. Focus: Resident #1 has an impaired cognitive function/dementia or impaired thought processes. Dementia Initiated 1/23/24 Revised: 1/25/24. Focus: The resident had potential/actual impairment to skin integrity: abrasion 1/19/24 Resident #1 had reddened area to forehead and old bruise/skin tear to left wrist. There was no care plan for falls at the time of record review. Record review of Resident #1 physician order dated 01/25/24 revealed the following: Order date: 01/10/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 2 of 37 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 01/27/2024 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 0609 Portable x-ray. Left rib series 2 view. Symptoms of bruising. Level of Harm - Minimal harm or potential for actual harm Order date/ Start Date: 1/19/24. Monitor left wrist and abrasion to forehead every shift. Residents Affected - Some Order date/ Start date: 11/30/23. Pain Assessment every 6 hours Order date/ Start date: 11/30/23. Tylenol Extra Strength Oral Tablet 5000 MG. Give 1000 mg by mouth every 6 hours as needed for pain. Order date/ Start date: 01/12/24. Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain related to pain unspecified joint. Record review of Resident #1 Pain level Summary, dated 1/26/24, revealed: 01/03/24-01/15/24 pain level a numerical rate of 0. 01/15/24 08:38 AM pain level at a numerical rate of 2. 01/15/24 12:59 -01/26/24 05:58 pain level a numerical rate of 0. Record review of Resident #1 MAR/TAR revealed the following: Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain in unspecified joint; start date 01/12/24: administered at 09:00 AM from 01/13/24-01/25/24; administered 09:00 PM 01/12/24-01/25/24. Tylenol Extra Strength Oral Tablet 1000 MG. Give 1000 mg by mouth every 6 hours as needed for pain.; start date 11/30/23: Was not administered 01/01/24-01/24/24; Administered 01/25/24; Not administered on 01/26/24. Record review of Resident #1 progress notes revealed the following: 01/04/24 at 11:15 AM Author: RN I Was notified by staff that when they went to help Resident #1 out of bed this morning that she non-verbally indicated pain to her left lower side and that she did not want to get up after that. Asked Resident #1 if she was experiencing any pain, she stated she was not. Did a physical assessment and Resident #1 recoiled when that area was physically touched. Notified Physician's team who came by the floor shortly after to inquire about the situation and to assess Resident #1. No orders given at this time. 01/07/24 at 6:14 PM Author: LVN L (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 3 of 37 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 01/27/2024 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 0609 Resident pleasantly confused and C/O right side flank pain. Level of Harm - Minimal harm or potential for actual harm 01/08/24 at 3:39 PM Author LVN O Residents Affected - Some Notified Physician team of lab results and that resident is having weakness and still having left sided pain and a little nausea and not eating or drinking. Family Member A called and wanted Doctors to see resident and assess resident. Family Member A wants doctor to call her while doctor is here. Encouraged resident to eat and drink. Family Member A voices that she always had a hard time getting doctor to call her and may have to change to another doctor out of facility. 11:15 (am) Resident c/o pain under left breast. Nurse took Tylenol to resident for pain then resident refused. Tylenol and voices she was not having any pain. Care provider encouraged resident to take Tylenol. resident took medication at 14:15 (2:15pm) Physician C here and assessed resident, resident denied pain voicing she is not having pain and has not had any pain. 1/10/24 at 9:14 PM Author: Nurse Manager M Resident has green/yellow bruising to left lower back. notified Physician team about pain to residents back and Family Member A wanting x-rays done. Physician team ordered rib series of the left side. x-rays returned and sent to physician team. 01/12/24 at 10:05 PM Author: Nurse Manager M Skin on 1/10/24 at 1249 (12:49pm). Nurse was notified that resident had large bruise to her side/back. Resident could not recall any fall or injury to that area. Notified Family Member A. Root Cause: fall 01/19/24 at 6:30 AM Author: RN Z LATE ENTRY Note Text: At 06:30 CNA F came to inform this nurse that while she was assisting resident to change the brief, she has notice resident's forehead is redden. And resident has old, scabbed wound and old bruised on the left wrist. Resident does not seem to be in pain. Asked resident what happened to her forehead, did you fall? Resident answered NO. Last night, all night, resident was sleeping in her bed, making frequent routine rounds did not hear any falls or noises. Resident is stable, went back to sleep. At 0635, called and spoke with Family Member A, informed her about the redness on her forehead and old healed bruised on left wrist. At 06:36, texted Physician B pager, no answer. At 06:40, paged again, still no answered. At 06:54, texted to inform the Physician Team on call phone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 4 of 37 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 01/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm 1/19/2024 07:10, The Physician Team texted back in response. Physician B himself called back and spoke with this nurse that he will make round to see resident today and will address the issues with Family Member A. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Residents Affected - Some Resident #1 bruise incident (bruise) 1/10/24 Resident #1 Skin incident (redness) 1/19/24 Record review of Resident #2's face sheet, 01/26/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include joint subsequent encounter (active treatment to an injury or injury that is in the recovery phase), displaced fracture od second cervical vertebra, cognitive communication deficit, unsteadiness on feet, weakness, muscle weakness. Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately intact. Section J1700. Fall History Did the resident have a fall anytime in the last month prior to admission/entry or reentry: Yes. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry: Yes. J2100. Recent Surgery requiring SNF Care Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay: Yes. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #2 Care plan revealed the following: Initiated 01/04/24 revised 01/16/24. Focus: Resident #2 is at risk for impaired skin integrity due to recent fall with fracture. admitted with wound to the right knew. Goal: Resident # 2 will have intact skin, free of redness, blisters, or discoloration through review date. Initiated 01/04/24. Focus: Resident #2 is at risk for falls due to recent history of falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 5 of 37 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 01/27/2024 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 0609 Goal: Resident #2 will be free of falls through the review date. Level of Harm - Minimal harm or potential for actual harm Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #2 was not on the incident accident report. Residents Affected - Some Record Review of Resident #2 Progress notes revealed the following: 1/17/2024 at 7:06 PM Author: LVN AA hospitalized Evidence of pain: yes, to right knee Injury assessment: right knee laceration with copious amount of blood Signs/symptoms relevant to injury: pain to right knee Modes of transportation: ambulance Nursing Comments: CNA called nurse to inform of call patient on floor patient did not hit head, she fell forward on knee from toilet in an attempt to clean self. CNA was outside door. patient was on floor laying under sink. EMS called and transported to the Hospital. Record review of hospital records dated 01/17/24 and discharge date of 01/22/24 revealed the following: History of present illness: Resident #2 had a right distal femoral replacement (total knee replacement) on 12/27/24. Resident #2 family member claimed resident fell in the shower. Skin Horizontal laceration with clotted blood below vertical surgical wound to the right knee. Record review of Resident #3's face sheet, 01/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia, difficulty walking, mood disorder, muscle weakness, cognitive communication deficit, unsteadiness on feet, and repeated falls. Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately intact. J1700. Fall History: No data in this section. J1800. Falls since admission. Has the resident had any falls since admission/entry or reentry or prior assessment: Yes. J1900 Number of Falls since admission or Reentry or Prior assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 6 of 37 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 01/27/2024 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 0609 No Injury Level of Harm - Minimal harm or potential for actual harm Section V: Care Area Assessment Falls were triggered and care planned. Residents Affected - Some Record review of Resident #3's Care plan revealed the following: Initiated 06/23/23 Revised on 01/06/23. Focus: Resident #3 is at risk for falls. Gait/balance problems. Ensure resident has walker when ambulating. 1/04/24: Resident is noted to have a fall- Redness noted to back. Goal: [NAME] will be free of falls through the review date. Initiated 07/21/23 Revised 07/21/23. Focus: Resident #3 has impaired cognitive status- has impaired decision making, poor safety awareness Goal: Resident #3 will maintain current level of cognitive function through the review date. Interventions: Communicate with the resident /family/ caregivers regarding resident's capabilities and needs. No care plan at the time of record review regarding his interactions with Resident #6. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Unwitnessed fall 01/04/24 Unwitnessed fall 01/08/24 Record review of Resident #3's progress notes revealed the following: 01/04/24 at 2:49 PM Author: LVN BB Staff heard a thud and noted resident on floor in resident's wife's room. Resident assisted to walker x2 assist. V/S and neuro checks initiated. Noted no reaction to light to both eyes. Skin assessment completed. Noted redness to middle of back. Notified family and doctor. No new orders at this time. 1/05/24 at 2:36 PM Author: Nurse Manager X IDT unwitnessed fall on 1/4/24. Skin assessment completed and no new orders. There was no progress note for the fall that occurred on 01/08/24. The following are notes post fall on 01/08/24: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 7 of 37 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 01/27/2024 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 0609 1/09/24 at 2:36 PM Author: Nurse Manager X Level of Harm - Minimal harm or potential for actual harm CNA reported patient was having a lot of pain to his left lower back from his fall on 1/8/2024. I notified physician's team and doctor came and did an exam on the area and in his assessment, patient did not have any bony tenderness there. He said continue Tylenol PRN if patient has pain. No x-ray ordered at this time. Residents Affected - Some 1/12/24 at 1:45 PM Author Nurse Manager X IDT unwitnessed fall on 1/8 Resident was seen on the floor by the window in a sitting position. I was sitting at the nurse's station on the computer. Resident #3 was sitting on the floor near the window in his bedroom. Assessed resident, got some help and using safety technique we helped the resident transfer back into his recliner. Resident stated he had gotten up from recliner to walk over to get his walker when suddenly he lost his balance and fell near the window and scraped his back with the wooden bench. Doctor and family notified of fall. No recent falls, infections, or wounds. No supplements needed. Root cause: [NAME] not within reach/resident lost balance. Implementation: Make sure walker is within reach. No progress notes regarding allegation that someone pushed Resident #1 and no progress note reflecting the resident-to-resident altercation. Record review of Resident #4's face sheet, 01/26/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (memory deficit) and mood disorder. Record review of Resident #4's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section A Acute Onset Mental Status Change: No evidence of an acute change in mental status. Section E: Behavior: No potential indicator of psychosis

E0200. Behavioral Symptom Physical, verbal, and other behavioral symptoms: 1. Behavior of this type occurred 1-3 days.

E0300. Overall Presence of behavioral Symptoms: Yes

E0800. Rejection of Care: 1. Behavior of this type occurred 1 to 3 days. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #4 Skin Tear incident (bruise) 1/25/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 8 of 37 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 01/27/2024 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 0609 Record review of Resident #4's progress notes revealed the following: Level of Harm - Minimal harm or potential for actual harm 01/25/24 at 10:43 AM Author: LVN N Residents Affected - Some Staff reported while changing resident clothing that skin tear to the L arm near the antecubital region, with some bruising. No pain or discomfort. Doctor notified with no new orders. Record review of Resident #5's face sheet, 01/26/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia. Record review of Resident #5's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section E Behavior No potential indicators of psychosis. Section V: Care Area Assessment Behavior was not triggered, or care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Bruise incident (Bruise) 1/25/24 Record review of Resident #5's progress notes revealed: 1/25/24 Resident received scheduled shower, CNA notified this nurse of a bruise to right upper inner arm. No pain or discomfort. Record review of Resident #6's face sheet, 01/27/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (memory deficit), cognitive communication deficit, psychotic disorder with delusions, and dementia. Record review of Resident #6's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section E-Behavior

E0100. Potential Indicators of psychosis: No data entered.

E0200. Behavioral Symptoms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 9 of 37 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 01/27/2024 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 0609 Other behavioral symptoms not directed towards others: 1 Behavior of this type occurred 1 to 3 days. Level of Harm - Minimal harm or potential for actual harm

E1100. Change in behavior or other symptoms. Residents Affected - Some How does residents' current behavior status, care rejection, or wandering compared to prior assessment: 2. Worse. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: No pertinent information regarding Resident #6 on this report Record review of progress notes did not reveal any information about Resident #6 having any physical altercation with anyone. During an interview on 01/25/24 at 1:07 PM, Care Giver E stated that she could not remember when she discovered the bruise. She stated she took a picture of the bruise and sent it to Family member A. She Said after looking at her phone that the date of her picture on her phone was 01/10/24. She said that she discovered the bruise because Resident #1 had a bowel movement, and she had her seated on the toilet. She said that when Resident #1 leaned over to grab toilet paper, she noticed a bruise on the left side of her back. She said she grabbed the phone, took a picture, and sent it to Family member A. She stated she then reported it to the nurse's station. She stated Family Member A must have called everyone. She stated that before the bruise, she had been unaware of any falls. She said that CNA J told her that Resident #1 had been complaining of pain for weeks. The Care Giver stated that she was unaware of any pain Resident #1 may have had as she did not complain. She stated she worked Monday through Friday and did a split shift. She said her hours were 8:00 AM to 2:00 PM and then 4:00 PM to 8:00 PM. She stated she was notified that Resident #1 had three fractured ribs. She stated that Resident #1 had another incident. She stated when she came to work Monday, 01/22/24, she had a black eye, scratch, and small bruise on her left arm and a red spot on her forehead. She said she did not know where those injuries came from. She said that she did not remember seeing those injuries when she worked on Friday, 01/19/24. She said Resident #1 did not have a roommate. She said Family Member A placed a camera in Resident #1 room. She said she did not report the second set of injuries to anyone because Family Member A was present, and the doctor said the injuries seemed to be consistent with a fall. The Caregiver stated she was not questioned about the first bruise, fractured ribs, or the second set of injuries on Resident #1. During an interview on 01/25/24 at 1:33 PM, Family Member A stated that although she received a picture of the bruise, it was not the first issue. She stated the first issue was Resident #1 complaining of pain. She said she thought it was abdominal pain based on the way the previous caregiver described it. She said Resident #1 hurt when she moved. She said on 01/04/24, Care Giver E was not present, but there was a different one. She said she reported the pain to RN I. She said it was her understanding that there was a member of the physician team on the memory unit, but her mother was not seen. She said RN I went into the room and asked Resident #1 about pain, and Resident #1 stated she did not have pain. Family member A stated this was when she was mad because they reported the pain for Resident #1. She said the next day, Friday, 01/05/24, was when she was on the phone with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 10 of 37 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 01/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #1. She said the staff were attempting to get Resident #1 up, and this was when she heard Resident #1 holler out because she was in pain. She said this concerned her greatly because Resident #1 had a high pain tolerance, and for her to holler out, it must have been bad. She said she was so shocked that she called the nurse to try and get the doctor to come and see her. She said she believed she reached out to RN I. She said she was told that the doctor did not see Resident #1 because they thought it was a UTI and they were just going to take a UA from Resident #1. She also said the physician team thought it was musculoskeletal (pain associated with arthritis). She stated that she attempted to follow up on the UA sample on Saturday (01/06/24) but could not contact anyone. She said she attempted to contact the nurse 20 or 30 times with no luck. She said she was originally told that the doctors do not come out on the weekend but was then told by another staff that the doctor had seen her mother. She said she found out from a couple of sources that when the doctor came the previous week, the doctor spoke with the facility nurse but did not examine Resident #1. She said she was told that they took the UA on 01/06/24. She said she had requested to the nurse RN I that blood be taken but was told that blood could not be taken over the weekend. She said she attempted to get the results the weekend of 01/6/24 and 01/07/24 and was told that the UA had been mislabeled and would have to try to get another sample. She said the staff on 01/07/24 was finally able to get a UA. She said she was told by the staff on 01/07/24 that they could draw blood on the weekends but that RN I did not write this request down. She said it was Monday (1/08/24) when they received the results of the UA. She said she tested positive for a UTI and was started on an antibiotic. She stated she was told on Tuesday that the physician would be at the facility to see Resident #1. She stated she arranged for her cousin to be at the facility. She stated her cousin was present when the doctor came. According to her cousin, the physician did not lift Resident #1 shirt or undress her to examine her. She stated she was told that the physician patted around on her a few times. She said that on 01/07/24, she was told by the nurse on duty that Resident #1 had pain under her rib. She said on Monday she wanted Resident #1 to have x-rays done on 01/08/24 but was told that Resident #1 would have to go to the hospital. She later found out that x-rays could be taken on the memory unit. She said although Resident #1 said she did not have pain, she started asking her in diverse ways to determine if she had pain. She said she would have to ask Resident #1 if it hurt when she moved; that was how she determined Resident #1 was experiencing pain. She said she does not believe Resident #1 received any pain medication. She said she was unaware of Resident #1 receiving any medication until Wednesday (01/10/24) or Thursday (01/11/24). She said after receiving a copy of the MAR, she became aware that Resident #1 had standing orders for Tylenol. She stated she was not made aware of this medication order. She said no one knows what happened to Resident #1 but that, according to the physicians, their best guess was a fall, especially after the second injury. The physician team and facility staff feel certain that Resident #1 could get off the floor if she fell. She said she was unsure if Resident #1 could get up off the floor if she fell. She said she asked Resident #1 if she had fallen, and she was told, No, not that I know of. Family Member A said on Friday, 01/19/24, she had planned to drive to the facility to see Resident #1, and around 6:30 AM, she received a call from LVN G. She said LVN G told her that Resident #1 had a hurt wrist and red marks on her forehead. She said LVN G may have used the term bruising. She said LVN G told her that the previous night, Resident #1 had been checked on, and she was unaware of any falls or issues from the previous night. She stated LVN G wondered if Resident #1 had fallen. She said if a fall had occurred, it would have occurred on Thursday (01/18/24) because she had not heard from the caregiver. She said that they had a meeting on 01/22/24, and Physician B stated that no further evaluation needed to be done. She said it was Monday when she paid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 11 of 37 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 01/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some attention to the blackness on Resident #1 eye. It was concluded that Resident #1 may have had her glasses on when she fell. Family Member A stated this did not make sense to her because if she had fallen at night, she would not have had her glasses on. She said no one had confirmed what happened to Resident #1. She said she was unaware of any additional interventions since the fracture. She said she was informed that she could put cameras in the room if she wanted to. She said the meeting on 01/22/24 was when they first suggested a fall mat. She said that some items also went missing that was reported. She said Care Giver E air pods and watch went missing. She said Resident #1 Apple watch also went missing simultaneously. She said this occurred around the time of the discovery of the fractured ribs. She stated that she thought about Resident #1's purse when this happened. She stated she did not want to alert anyone to the purse because it could also get stolen. She stated she was told by staff that a police report could be filed. She stated she was told that the staff would keep an eye out for the missing items. Resident #1 purse and wallet were confirmed missing on 01/13/24. She said she had not witnessed a fall since the cameras had been placed in Resident #1 room. During an interview on 01/25/24 at 2:45 PM, CNA H stated she came in to work one day (unsure of the date), and staff stated that Resident #3 had fallen. She stated she saw the bruises on his back. She stated this was a couple of weeks ago from the interview. She stated it was an unwitnessed fall, and Resident #3 was not with it, meaning he could not tell you what happened. During an interview on 01/25/24 at 3:15 PM, RN I stated she did not know much about Resident #1. She stated she may be susceptible to falling. She stated if she fell or was in pain, she would not say anything because Resident #1 does not like people fussing over her. She stated she believed that Resident #1 was capable of getting back up if she were to fall on the floor. She stated Family Member A had had some concerns, but she would not consider them complaints. She stated the last thing she remembered was Resident #1 not eating breakfast, and Family Member A wanted to ensure a tray was saved. She said the only time Resident #1 complained about the pain was when an x-ray was conducted, the doctor came out, and this was when Resident #1 had fractured ribs. She said Family Member A was concerned about Resident #1 receiving a UA, but she was able to provide a sample, and it turned out she had a UTI. She said she could not say an actual timeline because she had worked a lot with many residents. She said it was believed that the fractured ribs came from a fall. She said the last time she was on the memory unit; she observed the abrasion on her forehead and her bruised wrist. She stated it was speculated that it was from a fall, but they did not know what caused the second care of injuries. She stated she received a report from the overnight nurse but could not remember when or which nurse gave her report. She said she was told that all notifications were made to management staff and the doctor. She said she observed Resident #1 having a full range of motion in both wrists. She stated she was unsure if any checks were done to her head. She said she was not sure why no x-rays were conducted. She stated she had been questioned about Resident #1 but not Resident #4 or Resident #5. During an interview on 01/25/24 at 3:40 PM, CNA J stated she did not know what was happening with Resident #1. She stated it was her understanding that the overnight shift does not bother the residents as much. They check their briefs and try not to wake them. She stated on 01/05/24, she went to the room to get Resident #1 up, and she did not want to get up. She said Resident #1 was acting cranky the morning of 01/05/24. She said she was concerned. She said Resident #1 was on the phone with her daughter. She stated she went to get CNA K for assistance. She said it took her and CNA K to get Resident #1 to the restroom. She said at this time, Resident #1 was extensive, and normally, she was limited. She said Resident #1 normally does not require much assistance as she did on 01/05/24. She said when she got to the restroom, she lifted her shirt but did not see anything. She said Resident #1 was in pain the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 12 of 37 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 01/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some entire weekend. She stated that they had to baby Resident #1 all weekend. She stated that she did not know if Resident #1 received any pain medication. She stated they were very concerned about her condition. She said they reported it to RN I on Friday (01/05/24) and Saturday (01/06/24). She stated on Sunday that the nurse was LVN L, but she was unsure. She reported to the nurse each time Resident #1 was in pain. She stated she never knew where the fractures came from. She said there was no furniture out of place when she walked into the room. She stated that resident #1 was not always steady. She said she was unsure if Resident #1 could get off the floor if she fell. She stated that the bruise on her wrist occurred the previous week. She stated that 01/19/24 Resident #1 had a bruise on her wrist. She stated that she noticed that there was blood on the bed. She stated she notified RN I. She said she could not remember what RN I responded. She said she did not see resident #1 forehead until Sunday (01/21/24). She said she did not notice her forehead. She said she noticed Resident #1 eye on 01/24/24. She said she was unsure if management knew about the second set of injuries. She said RN I and Nurse Manager M knew and did not know where those injuries came from. She stated there were no interventions put in place from the fracture, but as of 01/24/24, a format was placed in Resident #1 room. She stated Resident #1 was a proud woman, and she did sometimes get up on her own. She stated there were times when she would place her clothes next to her and walk out, and by the time she got back, Resident #1 would have already dressed. She stated that nurse manager M had spoken to her about resident #1's injuries. It is believed that she may be getting up at night. CNA J provided no information about Residents #4 and #5. During an interview on 01/25/24 at 3:56 PM, CNA K stated that regarding Resident #1, she had no idea how she got the fractures. She stated she did write a statement and gave it to nurse manager M. She sta[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 13 of 37 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 01/27/2024 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 0610 Respond appropriately to all alleged violations. 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 have evidence that all alleged violations were thoroughly investigated for 6 of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) in that: Residents Affected - Some The ADM and the DON failed thoroughly investigate Resident #1's injuries of unknown origin that were first identified on 01/19/24. Those injuries included an abrasion to the forehead, bruising and skin tear to the left wrist and bruising to her eye. The ADM and the DON failed to thoroughly investigate Resident #1's misappropriation of items (apple watch, wallet, and purse). The ADM and the DON failed to thoroughly investigate Resident #2's unwitnessed fall that caused her to be transported by EMS to the hospital with a horizontal laceration below vertical surgical wound to her right knee. The ADM and the DON failed to thoroughly investigate Resident #3's allegation of Resident #6 had pushed him. The ADM and the DON failed to thoroughly investigate Resident #3's resident to resident altercation where staff observed him being slapped by Resident #6. The ADM and the DON failed to thoroughly investigate Resident #4's injury of unknow origin that revealed a bruise to her left inner arm. The ADM and the DON failed to thoroughly investigate Resident #5's injury of unknow origin that revealed a bruise and skin tear to her left elbow. The ADM and the DON failed to thoroughly investigate Resident #6's resident to resident altercation where she was observed by staff slapping Resident #3. Findings included: Record review of Resident #1's face sheet, 01/25/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include cognitive communication deficit, dementia (loss of cognitive/memory function) Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section J0200: Should pain Assessment be conducted. Yes All associated areas associated with pain were blank. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 14 of 37 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 01/27/2024 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 0610 J1700 Fall History Level of Harm - Minimal harm or potential for actual harm All areas in this section were blank. Section V: Care Area Assessment Residents Affected - Some Falls were triggered and care planned. Record review of Resident #1 Care plan revealed the following: Initiated 12/12/23 Revised: 12/12/23. Focus: Resident #1 had a communication problem Goal: Resident #1 will be able to make basic needs known on a daily basis Intervention: Anticipate and meet needs Initiated 12/12/2023 Revised 12/12/23. Focus: Resident #1 has an impaired cognitive function/dementia or impaired thought processes. Dementia Initiated 1/23/24 Revised: 1/25/24. Focus: The resident had potential/actual impairment to skin integrity: abrasion 1/19/24 Resident #1 had reddened area to forehead and old bruise/skin tear to left wrist. There was no care plan for falls at the time of record review. Record review of Resident #1 physician order dated 01/25/24 revealed the following: Order date: 01/10/24 Portable x-ray. Left rib series 2 view. Symptoms of bruising. Order date/ Start Date: 1/19/24. Monitor left wrist and abrasion to forehead every shift. Order date/ Start date: 11/30/23. Pain Assessment every 6 hours Order date/ Start date: 11/30/23. Tylenol Extra Strength Oral Tablet 5000 MG. Give 1000 mg by mouth every 6 hours as needed for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 15 of 37 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 01/27/2024 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 0610 Order date/ Start date: 01/12/24. Level of Harm - Minimal harm or potential for actual harm Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain related to pain unspecified joint. Residents Affected - Some Record review of Resident #1 Pain level Summary, dated 1/26/24, revealed: 01/03/24-01/15/24 pain level a numerical rate of 0. 01/15/24 08:38 AM pain level at a numerical rate of 2. 01/15/24 12:59 -01/26/24 05:58 pain level a numerical rate of 0. Record review of Resident #1 MAR/TAR revealed the following: Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain in unspecified joint; start date 01/12/24: administered at 09:00 AM from 01/13/24-01/25/24; administered 09:00 PM 01/12/24-01/25/24. Tylenol Extra Strength Oral Tablet 1000 MG. Give 1000 mg by mouth every 6 hours as needed for pain.; start date 11/30/23: Was not administered 01/01/24-01/24/24; Administered 01/25/24; Not administered on 01/26/24. Record review of Resident #1 progress notes revealed the following: 01/04/24 at 11:15 AM Author: RN I Was notified by staff that when they went to help Resident #1 out of bed this morning that she non-verbally indicated pain to her left lower side and that she did not want to get up after that. Asked Resident #1 if she was experiencing any pain, she stated she was not. Did a physical assessment and Resident #1 recoiled when that area was physically touched. Notified Physician's team who came by the floor shortly after to inquire about the situation and to assess Resident #1. No orders given at this time. 01/07/24 at 6:14 PM Author: LVN L Resident pleasantly confused and C/O right side flank pain. 01/08/24 at 3:39 PM Author LVN O Notified Physician team of lab results and that resident is having weakness and still having left sided pain and a little nausea and not eating or drinking. Family Member A called and wanted Doctors to see resident and assess resident. Family Member A wants doctor to call her while doctor is here. Encouraged resident to eat and drink. Family Member A voices that she always had a hard time getting doctor to call her and may have to change to another doctor out of facility. 11:15 (am) Resident c/o pain under left breast. Nurse took Tylenol to resident for pain then resident refused. Tylenol and voices she was not having any pain. Care provider encouraged resident to take Tylenol. resident took medication at 14:15 (2:15pm) Physician C here and assessed resident, resident denied pain voicing she is not having pain and has not had any pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 16 of 37 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 01/27/2024 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 0610 01/10/24 at 9:14 PM Author Nurse Manager M Level of Harm - Minimal harm or potential for actual harm Resident has green/yellow bruising to left lower back. Residents Affected - Some notified Physician team about pain to residents back and Family Member A wanting x-rays done. Physician team ordered rib series of the left side. x-rays returned and sent to physician team. 01/12/24 at 10:05 PM Author: Nurse Manager M Skin on 1/10/24 at 1249 (12:49pm). Nurse was notified that resident had large bruise to her side/back. Resident could not recall any fall or injury to that area. Notified Family Member A. Root Cause: fall 01/19/24 at 6:30 AM Author: RN Z LATE ENTRY Note Text: At 06:30 CNA F came to inform this nurse that while she was assisting resident to change the brief, she has notice resident's forehead is redden. And resident has old, scabbed wound and old bruised on the left wrist. Resident does not seem to be in pain. Asked resident what happened to her forehead, did you fall? Resident answered NO. Last night, all night, resident was sleeping in her bed, making frequent routine rounds did not hear any falls or noises. Resident is stable, went back to sleep. At 0635, called and spoke with Family Member A, informed her about the redness on her forehead and old healed bruised on left wrist. At 06:36, texted Physician B pager, no answer. At 06:40, paged again, still no answered. At 06:54, texted to inform the Physician Team on call phone. 1/19/2024 07:10, The Physician Team texted back in response. Physician B himself called back and spoke with this nurse that he will make round to see resident today and will address the issues with Family Member A. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #1 bruise incident (bruise) 1/10/24 Resident #1 Skin incident (redness) 1/19/24 Record review of Resident #2's face sheet, 01/26/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include joint subsequent encounter (active treatment to an injury or injury that is in the recovery phase), displaced fracture of second cervical vertebra, cognitive communication deficit, unsteadiness on feet, weakness, muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 17 of 37 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 01/27/2024 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 0610 Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Level of Harm - Minimal harm or potential for actual harm Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately intact. Residents Affected - Some Section J1700. Fall History Did the resident have a fall anytime in the last month prior to admission/entry or reentry: Yes. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry: Yes. J2100. Recent Surgery requiring SNF Care Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay: Yes. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #2 Care plan revealed the following: Initiated 01/04/24 revised 01/16/24. Focus: Resident #2 is at risk for impaired skin integrity due to recent fall with fracture. admitted with wound to the right knew. Goal: Resident # 2 will have intact skin, free of redness, blisters, or discoloration through review date. Initiated 01/04/24. Focus: Resident #2 is at risk for falls due to recent history of falls. Goal: Resident #2 will be free of falls through the review date. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #2 was not on the incident accident report. Record Review of Resident #2 Progress notes revealed the following: 1/17/2024 at 7:06 PM Author: LVN AA hospitalized Evidence of pain: yes, to right knee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 18 of 37 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 01/27/2024 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 0610 Injury assessment: right knee laceration with copious amount of blood Level of Harm - Minimal harm or potential for actual harm Signs/symptoms relevant to injury: pain to right knee Modes of transportation: ambulance Residents Affected - Some Nursing Comments: CNA called nurse to inform of call patient on floor patient did not hit head, she fell forward on knee from toilet in an attempt to clean self. CNA was outside door. patient was on floor laying under sink. EMS called and transported to the Hospital. Record review of hospital records dated 01/17/24 and discharge date of 01/22/24 revealed the following: History of present illness: Resident #2 had a right distal femoral replacement (total knee replacement) on 12/27/24. Resident #2 family member claimed resident fell in the shower. Skin Horizontal laceration with clotted blood below vertical surgical wound to the right knee. Record review of Resident #3's face sheet, 01/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include dementia, difficulty walking, mood disorder, muscle weakness, cognitive communication deficit, unsteadiness on feet, and repeated falls. Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately intact. J1700. Fall History: No data in this section. J1800. Falls since admission. Has the resident had any falls since admission/entry or reentry or prior assessment: Yes. J1900 Number of Falls since admission or Reentry or Prior assessment No Injury Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #3 Care plan revealed the following: Initiated 06/23/23 Revised o on 01/06/23. Focus: Resident #3 is at risk for falls. Gait/balance problems. Ensure resident has walker when ambulating. 1/04/24: Resident is noted to have a fall- Redness noted to back. Goal: [NAME] will be free of falls through the review date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 19 of 37 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 01/27/2024 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 0610 Initiated 07/21/23 Revised 07/21/23. Level of Harm - Minimal harm or potential for actual harm Focus: Resident #3 has impaired cognitive status- has impaired decision making, poor safety awareness Goal: Resident #3 will maintain current level of cognitive function through the review date. Residents Affected - Some Interventions: Communicate with the resident /family/ caregivers regarding residents' capabilities and needs. No care plan at the time of record review regarding his interactions with Resident #6. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Unwitnessed fall 01/04/24 Unwitnessed fall 01/08/24 Record review of Resident #3 progress notes revealed the following: 01/04/24 at 2:49 PM Author: LVN BB Staff heard a thud and noted resident on floor in resident's wife's room. Resident assisted to walker x2 assist. V/S and neuro checks initiated. Noted no reaction to light to both eyes. Skin assessment completed. Noted redness to middle of back. Notified family and doctor. No new orders at this time. 1/05/24 at 2:36 PM Author: Nurse Manager X IDT unwitnessed fall on 1/4/24. Skin assessment completed and no new orders. There was no progress note for the fall that occurred on 01/08/24. The following are notes post fall on 01/08/24: 1/09/24 at 2:36 PM Author: Nurse Manager X CNA reported patient was having a lot of pain to his left lower back from his fall on 1/8/2024. I notified physician's team and doctor came and did an exam on the area and in his assessment, patient did not have any bony tenderness there. He said continue Tylenol PRN if patient has pain. No x-ray ordered at this time. 1/12/24 at 1:45 PM Author Nurse Manager X IDT unwitnessed fall on 1/8 Resident was seen on the floor by the window in a sitting position. I was sitting at the nurse's station on the computer. Resident #3 was sitting on the floor near the window in his bedroom. Assessed resident, got some help and using safety technique we helped the resident transfer back into his recliner. Resident stated he had gotten up from recliner to walk over to get his walker when suddenly he lost his balance and fell near the window and scraped his back with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 20 of 37 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 01/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the wooden bench. Doctor and family notified of fall. No recent falls, infections, or wounds. No supplements needed. Root cause: [NAME] not within reach/resident lost balance. Implementation: Make sure walker is within reach. No progress notes regarding allegation that someone pushed Resident #1 and no progress note reflecting the resident-to-resident altercation. Record review of Resident #4's face sheet, 01/26/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (memory deficit) and mood disorder. Record review of Resident #4's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section A Acute Onset Mental Status Change: No evidence of an acute change in mental status. Section E: Behavior: No potential indicator of psychosis

E0200. Behavioral Symptom Physical, verbal, and other behavioral symptoms: 1. Behavior of this type occurred 1-3 days.

E0300. Overall Presence of behavioral Symptoms: Yes

E0800. Rejection of Care: 1. Behavior of this type occurred 1 to 3 days. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #4 Skin Tear incident (bruise) 1/25/24 Record review of Resident #4 progress notes revealed the following: 01/25/24 at 10:43 AM Author: LVN N Staff reported while changing resident clothing that skin tear to the L arm near the antecubital region, with some bruising. No pain or discomfort. Doctor notified with no new orders. Record review of Resident #5's face sheet, 01/26/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia. Record review of Resident #5's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 21 of 37 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 01/27/2024 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 0610 resident's cognition was severely impaired. Level of Harm - Minimal harm or potential for actual harm Section E Behavior No potential indicators of psychosis. Residents Affected - Some Section V: Care Area Assessment Behavior was not triggered, or care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Bruise incident (Bruise) 1/25/24 Record review of Resident #5 progress notes revealed: 1/25/24 Resident received scheduled shower; CNA notified this nurse of a bruise to right upper inner arm. No pain or discomfort. Record review of Resident #6's face sheet, 01/27/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (memory deficit), cognitive communication deficit, psychotic disorder with delusions, and dementia. Record review of Resident #06's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section E-Behavior

E0100. Potential Indicators of psychosis: No data entered.

E0200. Behavioral Symptoms Other behavioral symptoms not directed towards others: 1 Behavior of this type occurred 1 to 3 days.

E1100. Change in behavior or other symptoms. How does residents' current behavior status, care rejection, or wandering compared to prior assessment: 2. Worse. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 22 of 37 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 01/27/2024 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 0610 No pertinent information regarding Resident #6 on this report Level of Harm - Minimal harm or potential for actual harm Record review of progress notes did not reveal any information about Resident #6 having any physical altercation with anyone. Residents Affected - Some During an interview on 01/25/24 at 1:07 PM, Care Giver E stated that she could not remember when she discovered the bruise. She stated she took a picture of the bruise and sent it to Family member A. She Said after looking at her phone that the date of her picture on her phone was 01/10/24. She said that she discovered the bruise because Resident #1 had a bowel movement, and she had her seated on the toilet. She said that when Resident #1 leaned over to grab toilet paper, she noticed a bruise on the left side of her back. She said she grabbed the phone, took a picture, and sent it to Family member A. She stated she then reported it to the nurse's station. She stated Family Member A must have called everyone. She stated that before the bruise, she had been unaware of any falls. She said that CNA J told her that Resident #1 had been complaining of pain for weeks. The Care Giver stated that she was unaware of any pain Resident #1 may have had as she did not complain. She stated she worked Monday through Friday and did a split shift. She said her hours were 8:00 AM to 2:00 PM and then 4:00 PM to 8:00 PM. She stated she was notified that Resident #1 had three fractured ribs. She stated that Resident #1 had another incident. She stated when she came to work Monday, 01/22/24, she had a black eye, scratch, and small bruise on her left arm and a red spot on her forehead. She said she did not know where those injuries came from. She said that she did not remember seeing those injuries when she worked on Friday, 01/19/24. She said Resident #1 did not have a roommate. She said Family Member A placed a camera in Resident #1 room. She said she did not report the second set of injuries to anyone because Family Member A was present, and the doctor said the injuries seemed to be consistent with a fall. The Caregiver stated she was not questioned about the first bruise, fractured ribs, or the second set of injuries on Resident #1. During an interview on 01/25/24 at 1:33 PM, Family Member A stated that although she received a picture of the bruise, it was not the first issue. She stated the first issue was Resident #1 complaining of pain. She said she thought it was abdominal pain based on the way the previous caregiver described it. She said Resident #1 hurt when she moved. She said on 01/04/24, Care Giver E was not present, but there was a different one. She said she reported the pain to RN I. She said it was her understanding that there was a member of the physician team on the memory unit, but her mother was not seen. She said RN I went into the room and asked Resident #1 about pain, and Resident #1 stated she did not have pain. Family member A stated this was when she was mad because they reported the pain for Resident #1. She said the next day, Friday, 01/05/24, was when she was on the phone with Resident #1. She said the staff were attempting to get Resident #1 up, and this was when she heard Resident #1 holler out because she was in pain. She said this concerned her greatly because Resident #1 had a high pain tolerance, and for her to holler out, it must have been bad. She said she was so shocked that she called the nurse to try and get the doctor to see her. She said she believed she reached out to RN I. She said she was told that the doctor did not see Resident #1 because they thought it was a UTI and they were just going to take a UA from Resident #1. She also said the physician team thought it was musculoskeletal (pain associated with arthritis). She stated that she attempted to follow up on the UA sample on Saturday (01/06/24) but could not contact anyone. She said she attempted to contact the nurse 20 or 30 times with no luck. She said she was originally told that the doctors do not come out on the weekend but was then told by another staff that the doctor had seen her mother. She said she found out from a couple of sources that when the doctor came the previous week, the doctor spoke with the facility nurse but did not examine Resident #1. She said she was told that they took the UA on 01/06/24. She said she had requested to the nurse RN I that blood be taken but was told that blood could not be taken over the weekend. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 23 of 37 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 01/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said she attempted to get the results the weekend of 01/6/24 and 01/07/24 and was told that the UA had been mislabeled and would have to try to get another sample. She said the staff on 01/07/24 was finally able to get a UA. She said she was told by the staff on 01/07/24 that they could draw blood on the weekends but that RN I did not write this request down. She said it was Monday (1/08/24) when they received the results of the UA. She said she tested positive for a UTI and was started on an antibiotic. She stated she was told on Tuesday that the physician would be at the facility to see Resident #1. She stated she arranged for her cousin to be at the facility. She stated her cousin was present when the doctor came. According to her cousin, the physician did not lift Resident #1 shirt or undress her to examine her. She stated she was told that the physician patted around on her a few times. She said that on 01/07/24, she was told by the nurse on duty that Resident #1 had pain under her rib. She said on Monday she wanted Resident #1 to have x-rays done on 01/08/24 but was told that Resident #1 would have to go to the hospital. She later found out that x-rays could be taken on the memory unit. She said although Resident #1 said she did not have pain, she started asking her in diverse ways to determine if she had pain. She said she would have to ask Resident #1 if it hurt when she moved; that was how she determined Resident #1 was experiencing pain. She said she does not believe Resident #1 received any pain medication. She said she was unaware of Resident #1 receiving any medication until Wednesday (01/10/24) or Thursday (01/11/24). She said after receiving a copy of the MAR, she became aware that Resident #1 had standing orders for Tylenol. She stated she was not made aware of this medication order. She said no one knows what happened to Resident #1 but that, according to the physicians, their best guess was a fall, especially after the second injury. The physician team and facility staff feel certain that Resident #1 could get off the floor if she fell. She said she was unsure if Resident #1 could get up off the floor if she fell. She said she asked Resident #1 if she had fallen, and she was told, No, not that I know of. Family Member A said on Friday, 01/19/24, she had planned to drive to the facility to see Resident #1, and around 6:30 AM, she received a call from LVN G. She said LVN G told her that Resident #1 had a hurt wrist and red marks on her forehead. She said LVN G may have used the term bruising. She said LVN G told her that the previous night, Resident #1 had been checked on, and she was unaware of any falls or issues from the previous night. She stated LVN G wondered if Resident #1 had fallen. She said if a fall had occurred, it would have occurred on Thursday (01/18/24) because she had not heard from the caregiver. She said that they had a meeting on 01/22/24, and Physician B stated that no further evaluation needed to be done. She said it was Monday when she paid attention to the blackness on Resident #1 eye. It was concluded that Resident #1 may have had her glasses on when she fell. Family Member A stated this did not make sense to her because if she had fallen at night, she would not have had her glasses on. She said no one had confirmed what happened to Resident #1. She said she was unaware of any additional interventions since the fracture. She said she was informed that she could put cameras in the room if she wanted to. She said the meeting on 01/22/24 was when they first suggested a fall mat. She said that some items also went missing that was reported. She said Care Giver E air pods and watch went missing. She said Resident #1 Apple watch also went missing simultaneously. She said this occurred around the time of the discovery of the fractured ribs. She stated that she thought about Resident #1's purse when this happened. She stated she did not want to alert anyone to the purse because it could also get stolen. She stated she was told by staff that a police report could be filed. She stated she was told that the staff would keep an eye out for the missing items. Resident #1 purse and wallet were confirmed missing on 01/13/24. She said she had not witnessed a fall since the cameras had been placed in Resident #1 room. During an interview on 01/25/24 at 2:45 PM, CNA H stated she came in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 24 of 37 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 01/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to work one day (unsure of the date), and staff stated that Resident #3 had fallen. She stated she saw the bruises on his back. She stated this was a couple of weeks ago from the interview. She stated it was an unwitnessed fall, and Resident #3 was not with it, meaning he could not tell you what happened. During an interview on 01/25/24 at 3:15 PM, RN I stated she did not know much about Resident #1. She stated she may be susceptible to falling. She stated if she fell or was in pain, she would not say anything because Resident #1 does not like people fussing over her. She stated she believed that Resident #1 was capable of getting back up if she were to fall on the floor. She stated Family Member A had had some concerns, but she would not consider them complaints. She stated the last thing she remembered was Resident #1 not eating breakfast, and Family Member A wanted to ensure a tray was saved. She said the only time Resident #1 complained about the pain was when an x-ray was conducted, the doctor came out, and this was when Resident #1 had fractured ribs. She said Family Member A was concerned about Resident #1 receiving a UA, but she was able to provide a sample, and it turned out she had a UTI. She said she could not say an actual timeline because she had worked a lot with many residents. She said it was believed that the fractured ribs came from a fall. She said the last time she was on the memory unit; she observed the abrasion on her forehead and her bruised wrist. She stated it was speculated that it was from a fall, but they did not know what caused the second care of injuries. She stated she received a report from the overnight nurse but could not remember when or which nurse gave her report. She said she was told that all notifications were made to management staff and the doctor. She said she observed Resident #1 having a full range of motion in both wrists. She stated she was unsure if any checks were done to her head. She said she was not sure why no x-rays were conducted. She stated she had been questioned about Resident #1 but not Resident #4 or Resident #5. During an interview on 01/25/24 at 3:40 PM, CNA J stated she did not know what was happening with Resident #1. She stated it was her understanding that the overnight shift does not bother the residents as much. They check their briefs and try not to wake them. She stated on 01/05/24, she went to the room to get Resident #1 up, and she did not want to get up. She said Resident #1 was acting cranky the morning of 01/05/24. She said she was concerned. She said Resident #1 was on the phone with her daughter. She stated she went to get CNA K for assistance. She said it took her and CNA K to get Resident #1 to the restroom. She said at this time, Resident #1 was extensive, and normally, she was limited. She said Resident #1 normally does not require much assistance as she did on 01/05/24. She said when she got to the restroom, she lifted her shirt but did not see anything. She said Resident #1 was in pain the entire weekend. She stated that they had to baby Resident #1 all weekend. She stated that she did not know if Resident #1 received any pain medication. She stated they were very concerned about her condition. She said they reported it to RN I on Friday (01/05/24) and Saturday (01/06/24). She stated on Sunday that the nurse was LVN L, but she was unsure. She reported to the nurse each time Resident #1 was in pain. She stated she never knew where the fractures came from. She said there was no furniture out of place when she walked into the room. She stated that resident #1 was not always steady. She said she was unsure if Resident #1 could get off the floor if she fell. She stated that the bruise on her wrist occurred the previous week. She stated that 01/19/24 Resident #1 had a bruise on her wrist. She stated that she noticed that there was blood on the bed. She stated she notified RN I. She said she could not remember what RN I responded. She said she did not see resident #1 forehead until Sunday (01/21/24). She said she did not notice her forehead. She said she noticed Resident #1 eye on 01/24/24. She said she was unsure if management knew about the second set of injuries. She said RN I and Nurse Manager M knew and did not know where those injuries came from. She stated there were no interventions put in place from the fracture, but as of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 25 of 37 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 01/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm 01/24/24, a format was placed in Resident #1 room. She stated Resident #1 was a proud woman, and she did sometimes get up on her own. She stated there were times when she would place her clothes next to her and walk out, and by the time she got back, Resident #1 would have already dressed. She stated that nurse manager M had spoken to her about resident #1's injuries. It is believed that she may be getting up at night. CNA J provided no information about Residents #4 and #5. Residents Affected - Some During an interview on 01/25/24 at 3:56 PM, CNA K stated that regarding Resident #1, she had no idea how she got the fractures. She stated she did write a statement and gave it to nurse manager M. She stated the first set of fractures or injuries had occurred a few weeks ago. She stated that Resident #1 was complaining of side pain. She stated that she may be a little off on the date but was sure she told RN I. She stated on 01/05/24, she helped Resident #1's shower. She stated she assessed her body as they showered, and there were no bruises. She stated Resident #1 was in a lot of pain. She stated this was also reported to RN I. She stated Resident #1 and continued to complain [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 26 of 37 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 01/27/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for pain management. Residents Affected - Some The facility failed to assess, reassess, and/or take steps to manage Resident #1's pain when she presented with symptoms of pain. On 01/26/24 at 04:14 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/27/24 at 4:48 PM, the facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place the resident at risk of a decrease in quality of life due to pain. Findings included: Record review of Resident #1's face sheet, 01/25/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include cognitive communication deficit, dementia (loss of cognitive/memory function). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section J0200: Should pain Assessment be conducted. Yes All associated areas associated with pain were blank. J1700 Fall history. All areas following were blank. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #1 Care plan revealed the following: Initiated 12/12/23 Revised: 12/12/23. Focus: Resident #1 had a communication problem Goal: Resident #1 will be able to make basic needs known on a daily basis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 27 of 37 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 01/27/2024 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 0697 Intervention: Anticipate and meet needs. Level of Harm - Immediate jeopardy to resident health or safety Initiated 12/12/2023 Revised 12/12/23. Residents Affected - Some Initiated 1/23/24 Revised: 1/25/24. Focus: Resident #1 has an impaired cognitive function/dementia or impaired thought processes. Dementia Focus: The resident had potential/actual impairment to skin integrity: abrasion 1/19/24 Resident #1 had reddened area to forehead and old bruise/skin tear to left wrist. There was no care plan for falls at the time of record review. Record review of Resident #1's physician order dated 01/25/24 revealed the following: Order date: 01/10/24 Portable x-ray. Left rib series 2 view. Symptoms of bruising. Order date/ Start Date: 1/19/24. Monitor left wrist and abrasion to forehead every shift. Order date/ Start date: 11/30/23. Pain Assessment every 6 hours Order date/ Start date: 11/30/23. Tylenol Extra Strength Oral Tablet 5000 MG. Give 1000 mg by mouth every 6 hours as needed for pain. Order date/ Start date: 01/12/24. Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain related to pain unspecified joint. Record review of Resident #1's Pain level Summary, dated 1/26/24, revealed: 01/03/24-01/15/24 pain level a numerical rate of 0. 01/15/24 08:38 AM pain level at a numerical rate of 2. 01/15/24 12:59 -01/26/24 05:58 pain level a numerical rate of 0. Record review of Resident #1's MAR/TAR revealed the following: Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 28 of 37 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 01/27/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety unspecified joint; start date 01/12/24: administered at 09:00 AM from 01/13/24-01/25/24; administered 09:00 PM 01/12/24-01/25/24. Tylenol Extra Strength Oral Tablet 1000 MG. Give 1000 mg by mouth every 6 hours as needed for pain.; start date 11/30/23: Was not administered 01/01/24-01/24/24; Administered 01/25/24; Not administered on 01/26/24. Residents Affected - Some Record review of Resident #1's progress notes revealed the following: 01/04/24 at 11:15 AM Author: RN I Was notified by staff that when they went to help Resident #1 out of bed this morning that she non-verbally indicated pain to her left lower side and that she did not want to get up after that. Asked Resident #1 if she was experiencing any pain, she stated she was not. Did a physical assessment and Resident #1 recoiled when that area was physically touched. Notified Physician's team who came by the floor shortly after to inquire about the situation and to assess Resident #1. No orders given at this time. 01/07/24 at 6:14 PM Author: LVN L Resident pleasantly confused and C/O right side flank pain. 01/08/24 at 3:39 PM Author LVN O Notified Physician team of lab results and that resident is having weakness and still having left sided pain and a little nausea and not eating or drinking. Family Member A called and wanted Doctors to see resident and assess resident. Family Member A wants doctor to call her while doctor is here. Encouraged resident to eat and drink. Family Member A voices that she always had a hard time getting doctor to call her and may have to change to another doctor out of facility. 11:15 (am) Resident c/o pain under left breast. Nurse took Tylenol to resident for pain then resident refused. Tylenol and voices she was not having any pain. Care provider encouraged resident to take Tylenol. resident took medication at 14:15 (2:15pm) Physician C here and assessed resident, resident denied pain voicing she is not having pain and has not had any pain. 1/10/24 at 9:14 PM Author Nurse Manager M Resident has green/yellow bruising to left lower back. notified Physician team about pain to residents back and Family Member A wanting x-rays done. Physician team ordered rib series of the left side. x-rays returned and sent to physician team. 01/12/24 at 10:05 PM Author: Nurse Manager M Skin on 1/10/24 at 1249 (12:49pm). Nurse was notified that resident had large bruise to her side/back. Resident could not recall any fall or injury to that area. Notified Family Member A. Root Cause: fall 01/19/24 at 6:30 AM Author: RN Z (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 29 of 37 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 01/27/2024 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 0697 LATE ENTRY Level of Harm - Immediate jeopardy to resident health or safety Note Text: At 06:30 CNA F came to inform this nurse that while she was assisting resident to change the brief, she has notice resident's forehead is redden. And resident has old, scabbed wound and old bruised on the left wrist. Resident does not seem to be in pain. Asked resident what happened to her forehead, did you fall? Resident answered NO. Residents Affected - Some Last night, all night, resident was sleeping in her bed, making frequent routine rounds did not hear any falls or noises. Resident is stable, went back to sleep. At 0635, called and spoke with Family Member A, informed her about the redness on her forehead and old healed bruised on left wrist. At 06:36, texted Physician B pager, no answer. At 06:40, paged again, still no answered. At 06:54, texted to inform the Physician Team on call phone. 1/19/2024 07:10, The Physician Team texted back in response. Physician B himself called back and spoke with this nurse that he will make round to see resident today and will address the issues with Family Member A. Record review of the facility policy, Pain Management (07/01/2018), revealed the following: Key Components a pain screen is completed on every resident upon admission. For all residents with pain or diagnosis that is likely to cause pain, there is a care plan with risk factors identified. All residents regardless of risk are assess each shift for pain. All pain medications have been associated diagnosis. The community has a pain scale and is used appropriately for both cognitively intact and cognitively impaired residents. The goal of all pain management is what the resident and family member wish and is documented. All PRN pain medications are documented for nursing standards with date time reason and effect using numeric value. Position is called prompting for unrelieved pain. The resident representative is notified within 24 hours of introduction of opioid pain medication or pain that is not being relieved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 30 of 37 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 01/27/2024 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 0697 Assistant is in place to allow staff to report residents in pain promptly. Level of Harm - Immediate jeopardy to resident health or safety Policy Residents Affected - Some It is the commitment of the Health Center that pain will be relieved or reduced to an acceptable level of comfort, as determined by the resident, when able in order to improve their health, independence, and quality of life. It is the policy of the Health Center that each resident will be assessed using our interdisciplinary approach with regard to the level of pain or discomfort experience. Reviewing both medical and social history and all diagnosis which may indicate the potential for pain or discomfort, ongoing assessments will be performed together the data needed to maintain pain management for each resident. Objective To promote prompt and effective assessments, diagnosis and treatment of a resident who experiences pain or discomfort. Pain will be based on the residence verbal and nonverbal expressions of pain. Pain Management Components include, but are not limited to, the following: Pharmacological interventions was ordered by the physician. During an interview on 01/25/24 at 1:33 PM, Family Member A stated that although she received a picture of the bruise, it was not the first issue. She stated the first issue was Resident #1 complaining of pain. She said she thought it was abdominal pain based on the way the previous caregiver described it. She said Resident #1 hurt when she moved. She said on 01/04/24, Care Giver E was not present, but there was a different one. She said she reported the pain to RN I. She said it was her understanding that there was a member of the physician team on the memory unit, but her mother was not seen. She said RN I went into the room and asked Resident #1 about pain, and Resident #1 stated she did not have pain. Family member A stated this was when she was mad because they reported the pain for Resident #1. She said the next day, Friday, 01/05/24, was when she was on the phone with Resident #1. She said the staff were attempting to get Resident #1 up, and this was when she heard Resident #1 holler out because she was in pain. She said this concerned her greatly because Resident #1 had a high pain tolerance, and for her to holler out, it must have been bad. She said she was so shocked that she called the nurse to try and get the doctor to see her. She said she believed she reached out to RN I. She said she was told that the doctor did not see Resident #1 because they thought it was a UTI and they were just going to take a UA from Resident #1. She also said the physician team thought it was musculoskeletal (pain associated with arthritis). She stated that she attempted to follow up on the UA sample on Saturday (01/06/24) but could not contact anyone. She said she attempted to contact the nurse 20 or 30 times with no luck. She said she was originally told that the doctors do not come out on the weekend but was then told by another staff that the doctor had seen her mother. She said she found out from a couple of sources that when the doctor came the previous week, the doctor spoke with the facility nurse but did not examine Resident #1. She said she was told that they took the UA on 01/06/24. She said she had requested to the nurse RN I that blood be taken but was told that blood could not be taken over the weekend. She said she attempted to get the results the weekend of 01/6/24 and 01/07/24 and was told that the UA had been mislabeled and would have to try to get another sample. She said the staff on 01/07/24 was finally able to get a UA. She said she was told by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 31 of 37 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 01/27/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the staff on 01/07/24 that they could draw blood on the weekends but that RN I did not write this request down. She said it was Monday (1/08/24) when they received the results of the UA. She said she tested positive for a UTI and was started on an antibiotic. She stated she was told on Tuesday that the physician would be at the facility to see Resident #1. She stated she arranged for her cousin to be at the facility. She stated her cousin was present when the doctor came. According to her cousin, the physician did not lift Resident #1 shirt or undress her to examine her. She stated she was told that the physician patted around on her a few times. She said that on 01/07/24, she was told by the nurse on duty that Resident #1 had pain under her rib. She said on Monday she wanted Resident #1 to have x-rays done on 01/08/24 but was told that Resident #1 would have to go to the hospital. She later found out that x-rays could be taken on the memory unit. She said although Resident #1 said she did not have pain, she started asking her in diverse ways to determine if she had pain. She said she would have to ask Resident #1 if it hurt when she moved; that was how she determined Resident #1 was experiencing pain. She said she does not believe Resident #1 received any pain medication. She said she was unaware of Resident #1 receiving any medication until Wednesday (01/10/24) or Thursday (01/11/24). She said after receiving a copy of the MAR, she became aware that Resident #1 had standing orders for Tylenol. She stated she was not made aware of this medication order. She said no one knows what happened to Resident #1 but that, according to the physicians, their best guess was a fall, especially after the second injury. She said she asked Resident #1 if she had fallen, and she was told, No, not that I know of. During an interview on 01/25/24 at 3:15 PM, RN I stated she did not know much about Resident #1. She stated she may be susceptible to falling. She stated if she fell or was in pain, she would not say anything because Resident #1 does not like people fussing over her. She stated the last thing she remembered was Resident #1 not eating breakfast, and Family Member A wanted to ensure a tray was saved. She said the only time Resident #1 complained about the pain was when an x-ray was conducted, the doctor came out, and this was when Resident #1 had fractured ribs. She said Family Member A was concerned about Resident #1 receiving a UA, but she was able to provide a sample, and it turned out she had a UTI. She said she could not say an actual timeline because she had worked a lot with many residents. She said it was believed that the fractured ribs came from a fall. During an interview on 01/25/24 at 3:40 PM, CNA J stated she did not know what was happening with Resident #1. She stated it was her understanding that the overnight shift does not bother the residents as much. They check their briefs and try not to wake them. She stated on 01/05/24, she went to the room to get Resident #1 up, and she did not want to get up. She said Resident #1 was acting cranky the morning of 01/05/24. She said she was concerned. She said Resident #1 was on the phone with her daughter. She stated she went to get CNA K for assistance. She said it took her and CNA K to get Resident #1 to the restroom. She said at this time, Resident #1 was extensive, and normally, she was limited. She said Resident #1 normally does not require much assistance as she did on 01/05/24. She said when she got to the restroom, she lifted her shirt but did not see anything. She said Resident #1 was in pain the entire weekend. She stated that they had to baby Resident #1 all weekend. She stated that she did not know if Resident #1 received any pain medication. She stated they were very concerned about her condition. She said they reported it to RN I on Friday (01/05/24) and Saturday (01/06/24). She stated on Sunday that the nurse was LVN L, but she was unsure. She reported to the nurse each time Resident #1 was in pain. During an interview on 01/25/24 at 3:56 PM, CNA K stated that regarding Resident #1, she had no idea how she got the fractures. She stated she did write a statement and gave it to nurse manager M. She stated the first set of fractures or injuries had occurred a few weeks ago. She stated that Resident #1 was complaining of side pain. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 32 of 37 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 01/27/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some that she may be a little off on the date but was sure she told RN I. She stated on 01/05/24, she helped Resident #1's shower. She stated she assessed her body as they showered, and there were no bruises. She stated Resident #1 was in a lot of pain. She stated this was also reported to RN I. She stated Resident #1 and continued to complain of pain on her left side. She said the bruise did not show up during the time of the shower. She said it was the following Wednesday (01/10/24) when they noticed bruising. RN I looked at it and did not appear to be heavily concerned, but as a newer CNA, she followed the lead of her nurse. She said she did not know if Resident #1 received any pain medication. She stated that on all three days, she notified the nurse every time she complained of pain. She stated she did not document each time that she expressed the pain. She did not have a reason. She stated that they are able to document pain and skin issues in things such as bruises at least once a day. She said she did not document skin issues. She stated that Resident #1 was okay and comforted by the hot water during the shower. She stated that it took two staff to shower her; normally, it does not. She said you could see she was in pain because of facial grimacing. She stated that Resident #1 was a total assist over the weekend. She stated that each time, she did express the pain of Resident #1 to the nurse. She stated that sometimes, RN I was so calm that some things that require extra observation or attention may be overlooked, but she followed her nurse's lead. During an interview on 01/25/24 at 4:49 PM, Nurse Manager M stated that on 01/04/24, she went to complete her rounds in the memory unit. She stated that RN I was on the floor and that Resident #1 was complaining of flank (side) pain. She said when she arrived, one of the resident doctors was in the room, but she did not remember the doctor's name. She said she was unaware if she received pain medications that day. She said she did not receive any reports over the weekend that Resident #1 was in pain. She stated the following Monday (1/12/24), LVN O stated the doctor saw Resident #1 over the weekend. She was told that the doctor palpated her abdomen, and Resident #1 did not wince or make any signs of pain, so nothing was done. She said on Tuesday 10th, she received a call from RN I that staff discovered a bruise on her lower back. She stated she observed the bruise, and it looked old. She stated she notified the DON and ADM at this time. Family Member A was upset and suggested that an x-ray be conducted. RN, I had already messaged the physician team as well. The x-ray series was conducted, and that was when they found out about the fractured ribs. During an interview on 01/25/24 at 5:07 PM, Resident #1 stated she was not in pain. She stated she had never fallen. She stated the sore on her forehead had been there for a while, and the skin tear on her left arm also had been there. She was unable to tell the state investigator where the injuries came from. She stated that she had never fractured ribs, and the staff must have reported the incorrect information. An observation was made on 01/25/24 at 5:07 PM of Resident #1's forehead. There was a small red abrasion on her forehead. There was a small skin tear on her left wrist but no bruising. The state investigator observed Resident #1's back and showed no bruising. The state investigator observed a thin floor mat propped up on the wall. During an interview on 01/26/24 at 6:45 AM, CNA S stated that when they came back from their day off, she was told that Resident #1 had fractured ribs. She said before the identification of the fractured ribs, she was aware that Resident #1 had complained of side pain. She said the sitter had set her up, and Resident #1 had yelled out. She said she was unsure of the date, but whatever day it was, the nurse assessed Resident #1, and Resident #1 was tender near her ribs. She said she, as the CNA, was not instructed to do anything different. During an interview on 01/26/24 at 7:15 AM, CNA T stated she was aware of Resident #1's pain two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 33 of 37 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 01/27/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some weeks ago. She stated she remembered telling LVN O, and the response was to get a UA. She said that she was not aware of the date of the pain. She said she was unsure if it was before the fracture date. She said she was unaware of what caused the fractures. She said there were no falls during their shift or rotation. She said that Resident #5 bruise had to have happened on her days off. During an interview on 01/26/24 at 7:25 AM, LVN O stated one of Resident #1 sitters came and told one of the CNAs that Resident #1 had yelled out. She stated she went to assess her and mashed on her chest areas. She said Resident #1 was tender near her breast area. She stated she had an additional person come and asses her, but she could not remember who it was. She said she had asked the physicians about an x-ray but was told they did not need one because they thought it was a UTI. She said she went off duty, and when she returned, she found out that there was an x-ray obtained, and Resident #1 had a fracture. She was unsure of the exact date. She stated that Resident #1 did not say she was hurting, but she grimaced a little. She said she did not remember giving Resident #1 any medication. She stated the reason she did not give any medication was because when she was tender, she could not tell if it was because she was in pain, if it was the pressure she applied, or if it was the location on her breast. During an interview on 01/26/24 at 7:35 AM, RN I stated regarding Resident #1 that she could not remember if she administered any pain medication to Resident #1. She stated she had seen a lot of residents since then. She stated that if she administered medication, it would be on the MAR. She stated if she attempted to administer medication to Resident #1, that too would be on the MAR. During an interview on 01/26/24 at 9:15 AM, the DON stated she stated that regarding Resident #1, she noticed that Resident #1 grimaced with pain. She did not specify the date when she observed the grimace. She stated the day the bruise was noticed; the color of the bruise was yellow and scattered. She stated that the color of the bruise indicated that it had been there for a while. She stated the color of the bruise indicated that it had been there for 5-7 days. She stated she had been seen by the provider at least twice. She stated that although the private provider provides showers, the facility staff was supposed to assist. She stated when she conducted her investigation, she noticed that no pain medication was given. She stated that she ordered scheduled Tylenol for Resident #1. She stated when she assessed the resident (date not disclosed) that the resident verbally stated she did not have pain but expressed a facial grimace, which indicated Resident #1 did not know how to answer the question. She stated Resident #1 was in the memory unit and that Resident #1 had a cognitive deficit. She stated the fracture was reported to the state because it was an extensive injury, and Resident #1 could not tell us what happened. During an interview on 01/26/24 at 9:20 AM, Nurse Manager M stated that she was unaware of anyone reporting pain to her. She said she could not 100 percent say how Resident #1 received her fracture. She said when a bruise was yellow in tint, it was 5-7 days long. During an interview on 01/26/24 at 10:12 AM, the ADM stated regarding Resident #1 that the potential negative outcome is that if her pain or the resident's pain is not addressed, it can place the resident in a predicament where she could be experiencing constant pain or more pain. She stated the resident could have an underlying issue that was missed because the pain was not being addressed appropriately. She stated the pain was reported to the physician. She stated she was told that Resident #1 refused pain medication. She stated the physician team was originally looking to see if she had a UTI. She stated once they found out she had a UTI, then that was what was being addressed. She stated she was unaware that Resident #1 had pain before the identification of the fracture. She stated she expected pain medication to be administered if a resident was in pain and the dose reflected on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 34 of 37 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 01/27/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the MAR. She stated the refusal of medication should also be reflected on the MAR. She stated there was a system in place to monitor pain. She stated the nursing staff should be monitoring pain two times a day. She said staff should be asking residents if they are in pain. She stated that all pain should be reported at shift change. He stated staff should follow up to see if any treatment was effective, and the nurse managers should be notified. She stated that if the resident was reporting pain or staff was indicating pain; there should be a change on the pain scale in the EMR system. She stated she had been trained in pain management. She stated she did not observe Resident #1 in pain. She stated they all are responsible for pain management, but the DON oversaw. During an interview on 02/01/24 at 3:30 PM, Physician B stated his physician team was notified at 11:30 AM and went to see the resident. The complaint was pain in the lower trunk area. He stated Resident #1 was not in her room due to being in the assisted living portion of the facility with her daughter. He stated he had no names of the nurses who notified his team. He stated they looked at the symptoms of a UTI and wanted to rule that out first. He stated once the UA came back positive, they prescribed antibiotics. He stated the pain was described vaguely over the phone. He stated because the pain scales revealed 0 and no pain medication was given, he stated they considered everything was good. He stated the resident was seen by his team members multiple times, and no expression of pain was observed. He said that although Resident #1 expressed some tenderness during one examination, there was no reason to give Tylenol because there was no indication such as bruising. He stated when the nurse identified the bruise, it was described as yellow. He stated this color would have indicated that the bruise would have been there for at least a week. He stated because of the bruise and the request from Family member A was why the x-ray was conducted. He stated he also checked Resident #1 for pain, and because of his assessment, there was no pain. He stated he felt the Tylenol should have been scheduled rather than PRN because residents with dementia may not be able to attest to pain accurately. He stated that the testimony of the family and the staff was critical because it is difficult to gauge the quantity of pain. He stated fractured ribs were not a serious injury because the rib was not broken, and it was typically treated with pain management. He stated the pain was not treated prior because the physician team did not have any evidence of pain. He stated that with Resident #1's second set of injuries, he did not get an x-ray because Resident #1 could not move her hand. When the state surveyor asked about Resident #1 ability to function even through fractured ribs and if this would not be considered with the new injuries, Physician B stated he agreed and believed he later ordered an x-ray. He was unable to confirm if the x-ray had occurred and the outcome. He stated no one ever reported that she went from being a limited assist to an extensive. He stated that they would have treated the situation differently if this had been reported. He stated all decisions were made based on the documentation and physical assessments of Resident #1. The ADM and Interim ADM were notified on 01/26/24 at 4:14 PM and an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was submitted by the facility and was accepted on 01/27/24 at 09:45 AM and indicated the following: The facility failed to identify, treat, monitor and manage the resident's pain to the extent possible. Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 35 of 37 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 01/27/2024 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 0697 1. Level of Harm - Immediate jeopardy to resident health or safety Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 1/26/2024) Residents Affected - Some Resident # 1 was re-assessed for pain, the physician was updated with the results of the pain assessment and the plan of care for resident was reviewed and revised. The Director of Nursing or designee completed a pain assessment on all residents to identify any unmet pain needs/changes in pain. The residents' physicians were updated with the results of the pain assessment if new or worsening pain was identified. In response to the above-described pain assessment, pain regimen was reviewed and changed for residents as warranted. The care plans of residents directly affected by the deficient practice were updated to reflect new/revised resident specific pain management interventions. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 1/26/24) All the Facility's policies and procedures regarding pain/pain management were reviewed/revised. The Director of Nursing or designee educated all licensed nurses on appropriate pain management prior to their next shift. Education included review of the Facility's policy and procedure on pain and pain management and immediately notifying the physician. Education also included to assess for pain when it has been reported by family, non-licensed staff, and family caregivers immediately, administer pain medication as appropriate and according to physician orders. Contact physician as needed for additional interventions. Licensed nurses demonstrated pain assessment competency prior to their next shift. The Director of Nursing or designee will conduct compliance audits weekly for four weeks, then once per month for three months. Audits will consist of review of pain assessments and daily exception report. A QAPI PIP will be initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 1/26/2024. Action Plan to Ensure Relevant Recommendations are Followed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 36 of 37 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 01/27/2024 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 0697 Action/Task; Person assigned; date completed. Level of Harm - Immediate jeopardy to resident health or safety Complete pain assessment on resident # 1 and revise plan of care; DON/Nurse Managers; 1/26/24 Residents Affected - Some Notify physician of pain assessment findings/adjustment in pain medication; DON/Nurse Managers; 1/26/24 Complete pain assessment on all residents; DON/Nurse Managers; 1/26/24 Update care plans to reflect pain assessment findings/pain medication adjustment, DON/MDS/Nurse Managers Review/modify current policies as applicable to ensure appropriate procedures are in place to prevent harm/potential harm; Administrator/Director of Nursing/Regional Nurse Consultant; 1/26/24. Educate necessary staff on the Facility's procedures with return demonstration, where applicable; Regional Nurse Consultant/Administrator/DON; 1/26/24 Document PIP implementation, PIP progress, and QAA Committee Meeting Minutes where PIP is dis[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675997 If continuation sheet Page 37 of 37