Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on observation, interview, and record review, the facility failed to provide information to resident's
and their representatives on their rights related to filing grievances or concerns for 12 of 20 confidential
residents.
The facility failed to ensure 12 of 20 confidential residents were provided, through postings in prominent
locations; the Grievance Procedure, were provided access to the Grievance form, were provided
information regarding who the facility grievance officer was, their contact information, and how to file an
anonymous grievance.
This failure could place the residents at risk of unresolved grievances and decreased quality of life.
Findings include:
Interviews during Resident Council on, 04/24/2025 at 3:30pm, 12 confidential residents, stated they did not
have access to the Grievance form, they did not know they could file a Grievance anonymously, the
Grievance procedure had never been discussed in Resident Council, and they had not observed a posting
of the Grievance procedure in prominent locations. Residents attending Resident Council did not know
where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed.
The 12 residents in attendance had all been Residents of the facility for 6 plus months.
Observed prominent postings on 4/24/2025 at 4:45pm; the facility did not include instructions regarding the
Grievance procedure with any of the prominent postings. Grievance forms were not available and there was
no access to submit a Grievance anonymously.
Interview with the ADM on 4/25/2025 at 12:14pm; the ADM stated he was the Grievance Officer for the
facility. The ADM stated he was responsible for the review of Grievances and assign them to department
heads. The ADM stated there was no Grievance form available for the Residents, when Residents present
a Grievance issue to staff, the staff completed Grievances electronically on the Resident's behalf. The ADM
stated there was no procedure for Residents to submit grievances anonymously. The ADM stated the facility
should resolve grievances as soon as possible once they were submitted. The ADM stated he assigns the
grievance to the appropriate department, that department addresses the grievance, resolved the grievance,
and explained the resolution to the complainant. The resolution was documented electronically with the
original electronic Grievance. The ADM stated completed Grievances were kept in a notebook. The ADM
stated he monitored the Grievance process for success by following up with the staff member assigned to
resolve the Grievance, the ADM stated he would also meet with the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
675997
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
04/25/2025
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 0585
Level of Harm - Minimal harm
or potential for actual harm
complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for
ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance
procedure was not being discussed in Resident Council.
Record Review of the Grievance Policy.
Residents Affected - Some
Policy Statement
It is a policy to thoroughly investigate all resident and families' grievances/complaints. Resolution will be
documented on the facility grievance/concern form.
Policy Interpretation and Implementation
1.
Federal and state laws guarantee the right to submit a formal grievance to all residents of this facility.
1.
Grievance/complaint forms will be kept on each floor and in the social service office.
2.
Any staff member may assist a family member or resident in completing the facility form.
3.
Completed grievance forms will be given to the social service department. The social service department
will route the grievance to the appropriate department.
4.
Investigation will be completed by the appropriate staff member and follow up will be documented on the
form.
5.
After investigation and resolution, the completed form will be given to the administrator or designee for final
review.
6.
The social service director or designee will be responsible for logging all family and resident grievances in
the facility grievance log.
7.
Copies of the completed grievance form may be given to residents and/or family members as deemed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675997
If continuation sheet
Page 2 of 7
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
04/25/2025
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 0585
appropriate by the facility management.
Level of Harm - Minimal harm
or potential for actual harm
8.
Residents Affected - Some
Incidents/complaints involving alleged resident abuse will be directed to the Administrator for proper
reporting and investigation immediately.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675997
If continuation sheet
Page 3 of 7
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
04/25/2025
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve
food in accordance with professional standards for food service safety in 3 of 6 kitchens reviewed for
dietary services.
The facility failed to label and date foods stored in the refrigerator.
These failures could place residents at risk for food contamination and foodborne illness.
The findings included:
The following observations and interviews were made on 04/23/2025 beginning at 10:15 AM during the
initial observations of the kitchens:
Observation on 04/23/2025 at 10:45 AM of the 1st floor south kitchen revealed the following unlabeled and
undated items: 2 individual prepared parfaits and 6 individual pureed parfaits.
During an interview on 04/23/2025 at 10:50 AM the DM stated the parfaits were prepared on 04/23/2025.
The DM stated the parfaits were not dated with the date they were prepared since they planned to serve
them the same day. The DM stated if the parfaits were not used that day there would not be a way for a
someone to know what day they were prepared since they were not dated. The DM stated he would ensure
all prepared food items stored in the kitchen refrigerators were dated going forward to prevent expired food
from being served.
Observation on 04/23/2025 at 10:58 AM of the 2nd floor south kitchen revealed the following unlabeled and
undated items: 2 individual prepared parfaits, 1 individual pureed parfait, and 7 uncooked pasteurized eggs
(in a clear, unlabeled, plastic container).
Observation on 04/23/2025 at 11:29 AM of the 3rd floor south kitchen revealed the following unlabeled and
undated items: 3 individual pureed parfaits.
Observation on 04/23/2025 at 11:40 AM of the 3rd floor north kitchen revealed the following unlabeled and
undated items: 2 individual prepared parfaits and 1 individual pureed parfait.
During an interview on 04/25/2025 at 12:45 PM the DM stated all food in the kitchen refrigerators should
have been dated with a prepared date or an expiration date. The DM stated all dietary staff were
responsible for ensuring food was labeled and dated. The DM stated all dietary staff received training on
food preparation and storage upon hire and again during monthly in-service trainings. The DM stated
uncooked pasteurized eggs were sometimes stored in the units' kitchen refrigerators to be prepared fresh
on each unit. The DM stated the uncooked pasteurized eggs were removed from a larger dated container
and placed in a storage container. The DM stated the expectation was for dietary staff to rotate eggs when
new eggs were brought in. The DM stated there was no system in place to verify eggs were rotated or to
verify the use by date for each egg. The DM stated he planned to ensure all uncooked pasteurized eggs
were stored, in each unit's kitchen refrigerator, with a use by date going forward. The DM stated he
completed monthly audits on each unit's kitchen. The DM stated it was his expectation that regulations
were followed, and food items were labeled and dated properly. The DM stated it was important for food
times to be labelled and dated to ensure outdated food was not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675997
If continuation sheet
Page 4 of 7
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
04/25/2025
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
being served to prevent foodborne illness. The DM stated when food was not labelled and dated properly,
residents were at risk of getting food poisoning.
During an interview on 04/25/2025 at 1:30 PM the ADM stated it was the facility's policy that all food items
be properly labelled and dated. The ADM stated it was his expectation that all food was served fresh and
stored properly. The ADM stated all dietary staff were responsible for ensuring food was stored and dated
properly, and the DM was responsible for overseeing dietary staff. The ADM stated all prepared food should
have been labelled and dated in each kitchen's refrigerators. The ADM stated uncooked pasteurized eggs
should have been dated as well. The ADM stated all dietary staff received training pertaining to food
storage and preparation upon hire and during regular in-service trainings, held by the DM. The ADM stated
each kitchen was audited monthly by the DM and the facility's registered dietician. The ADM stated if food
was not labelled or dated properly, residents could have potentially received food that was not appropriate
for them, and residents could have received food that was not fresh and outdated which could have
potentially caused illness to the resident.
Record review of the undated facility policy titled Refrigerators and Freezers revealed the following
documentation:
Policy Statement:
This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will
observe food expiration guidelines.
Policy Interpretation and Implementation:
7. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of
delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are
completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food
are observed and use by dates are indicated once food is opened.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675997
If continuation sheet
Page 5 of 7
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
04/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carillon Inc
1717 A Norfolk Ave
Lubbock, TX 79416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to maintain an infection control program
designed to provide a safe, comfortable, and sanitary environment to help prevent the development and
transmission of communicable diseases for 1 of 20 residents (Resident #40) reviewed for infection control.
Residents Affected - Few
CNA A failed to sanitize her hands between glove changes during incontinent care for Resident #40.
This failure could place residents at risk for the spread of infection and cross contamination.
Findings included:
Record review of Resident #40's face sheet dated 04/25/25 revealed a [AGE] year-old male admitted on
[DATE] with the following diagnoses: acute respiratory failure (a condition causing inadequate oxygen in the
tissues), Parkinson's Disease (a disorder of the central nervous system that affects movement), shortness
of breath, and hypertension (high blood pressure).
Record review of Resident #40's comprehensive care plan dated 03/04/25 revealed the resident required
assistance with toileting needs and was incontinent of bowel and bladder.
Record review of Resident #40's Significant Change MDS assessment dated [DATE] revealed a BIMS
score of 0, indicating the resident's cognition was severely impaired. Further review of Section H-Bowel and
Bladder revealed: Urinary Continence - the resident was always incontinent. Bowel Continence - the
resident was always incontinent.
During an observation on 04/24/25 at 10:02 AM of incontinent care for Resident #40, CNA A washed her
hands, put on PPE, and performed male incontinent care. CNA A removed her gloves, put on a new pair of
gloves, and applied a new brief to Resident #40. CNA A removed her PPE and washed her hands following
the procedure. CNA A did not sanitize her hands between the glove change during incontinent care.
During an interview on 04/24/25 at 10:50 AM, CNA A stated she did not sanitize her hands between glove
changes while performing incontinent care for Resident #40. She stated she did not know why she skipped
the step of sanitizing her hands. She stated, Normally, I would sanitize my hands after removing my gloves,
but today I got in a hurry and forgot. CNA A stated she was trained on hand hygiene during her orientation
when she was hired. CNA A stated a potential negative outcome of failure to perform hand hygiene
between glove changes was cross-contamination.
During an interview on 04/25/25 at 11:41 AM, the ADM stated he was not aware that staff were not
observing proper hand hygiene between glove changes during resident care. He stated the DON and
administrative nursing staff were responsible to assure staff were trained on proper hand hygiene. The ADM
stated a potential negative outcome for failure to properly sanitize hands between glove changes was the
spread of bacteria and germs.
During an interview on 04/25/25 at 12:05 PM, the DON stated she was not aware that staff were not
observing proper hand hygiene between glove changes during resident care. She stated she and the
clinical managers were responsible to assure staff were trained on hand hygiene. She stated the facility
educator was responsible to conduct staff training monthly and as needed. The DON stated the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675997
If continuation sheet
Page 6 of 7
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
04/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carillon Inc
1717 A Norfolk Ave
Lubbock, TX 79416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
clinical managers made daily rounds on each unit to monitor staff for proper skills and training during
resident care. She stated a potential negative outcome for failure to perform hand hygiene between glove
changes was the spread of infection.
Record review of the facility's undated policy titled, Handwashing/Hand Hygiene, revealed:
Residents Affected - Few
Policy Statement
This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated
infections.
Policy Interpretation and Implementation
.
Indications for Hand Hygiene
1. Hand hygiene is indicated:
a. immediately before touching a resident.
f. before moving from work on a soiled body site to a clean body site on the same resident; and
g. immediately after glove removal.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675997
If continuation sheet
Page 7 of 7
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
FAQ · About this visit
Common questions about this visit
What happened during the April 25, 2025 survey of CARILLON INC?
This was a inspection survey of CARILLON INC on April 25, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARILLON INC on April 25, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordanc..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.