Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carillon Inc during CMS and state inspections, most recent first.
Twelve residents were not provided with information about their rights to file grievances, did not have access to grievance forms, and were unaware of the grievance procedure or the option to file anonymously. Grievance procedures were not posted in prominent locations, and the ADM confirmed there was no process for anonymous submission, with staff completing grievances electronically on residents' behalf.
Surveyors found that multiple kitchen refrigerators contained prepared parfaits and uncooked pasteurized eggs that were not labeled or dated, contrary to facility policy. Dietary staff confirmed that labeling and dating were not consistently performed, and there was no system to track the use-by dates for eggs once removed from their original packaging. The deficiency was identified despite staff training and regular audits.
A CNA did not sanitize her hands between glove changes while providing incontinent care to a resident with severe cognitive impairment and multiple medical conditions. The CNA acknowledged skipping the hand hygiene step, despite prior training. Facility leadership was unaware of this lapse, and facility policy requires hand hygiene after glove removal and before moving from a soiled to a clean body site.
A facility failed to ensure proper pharmaceutical services, leading to the improper storage and potential diversion of medications for a resident with severe pain. The resident, who had cancer and other conditions, was prescribed Morphine Sulfate. After the resident's discharge and subsequent death, a card of Morphine tablets and the narcotic sheet were found missing. The facility lacked a clear system for managing medications after a resident's discharge, contributing to the deficiency.
The facility failed to secure medication carts 4S1 and 4S2 on the fourth floor, leaving them unlocked and unattended. RN A, responsible for the carts, admitted to not locking them while attending to a resident, despite being trained to do so. Interviews with the Interim DON and ADM highlighted the importance of securing medication carts to prevent unauthorized access.
A facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including heart failure and severely impaired cognition. The care plan did not accurately reflect the resident's need for assistance with ADLs and nutritional needs during meals. Observations showed the resident required frequent cueing to eat, which was not documented in the care plan. Interviews with staff revealed a lack of awareness and monitoring of the care plan's accuracy, despite facility policies requiring comprehensive, updated care plans.
A resident with severe cognitive impairment and multiple medical conditions did not receive necessary assistance with eating while on in-room isolation. Despite requiring cuing assistance and being on a mechanically altered diet, the resident was not provided help during lunch and dinner, leading to inadequate food intake. A CNA assigned to the resident was not informed of her needs, highlighting a communication and training gap in the facility's procedures.
Failure to Provide Grievance Information and Access to Residents
Penalty
Summary
The facility failed to provide 12 out of 20 confidential residents with information regarding their rights to file grievances, including access to the grievance procedure, forms, and the ability to file grievances anonymously. During a Resident Council meeting, these residents reported that they had not been informed about the grievance process, did not know where to obtain grievance forms, were unaware of the option to file anonymously, and had not seen postings of the grievance procedure in prominent locations. All 12 residents had been living in the facility for over six months. Observations confirmed that the facility did not have grievance procedures posted in prominent areas, and grievance forms were not available for residents. An interview with the ADM revealed that there was no process for residents to submit grievances anonymously and that staff typically completed grievances electronically on behalf of residents. The ADM was unaware that the grievance procedure was not being discussed in Resident Council meetings. A review of the facility's grievance policy indicated that forms should be available on each floor and in the social service office, but this was not being followed in practice.
Failure to Label and Date Food Items in Facility Kitchens
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items stored in refrigerators across multiple kitchen units. Specifically, individual prepared and pureed parfaits, as well as uncooked pasteurized eggs stored in clear, unlabeled containers, were found without any labels or dates in several kitchen refrigerators. Dietary staff confirmed that parfaits were not dated if they were intended to be served the same day, and there was no system in place to track the preparation or expiration dates for eggs once removed from their original packaging. The facility's policy required all food items to be labeled and dated to ensure proper rotation and prevent expired food from being served. Interviews with the Dietary Manager (DM) and the Assistant Dietary Manager (ADM) revealed that all dietary staff were responsible for labeling and dating food, and that training on these procedures was provided upon hire and during monthly in-services. Despite these expectations and regular audits by the DM and the facility's registered dietician, the lack of labeling and dating persisted. The facility's written policy also specified that all food should be appropriately dated to ensure safe storage and prevent the use of expired items.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper hand hygiene protocols during incontinent care for a resident with severe cognitive impairment, Parkinson's Disease, acute respiratory failure, and incontinence of bowel and bladder. During the observed care, the CNA washed her hands and donned personal protective equipment (PPE) before beginning care, but after removing her gloves, she did not sanitize her hands before putting on a new pair of gloves and continuing with the procedure. The CNA completed the care and washed her hands only after removing her PPE at the end of the process. The CNA later acknowledged in an interview that she skipped the hand sanitizing step between glove changes, attributing it to being in a hurry, despite having received training on hand hygiene during orientation. Interviews with the administrator (ADM) and director of nursing (DON) revealed that they were not aware staff were omitting hand hygiene between glove changes during resident care. Both acknowledged that proper hand hygiene is necessary to prevent the spread of bacteria and infection, and that staff are trained and monitored for compliance. Review of the facility's hand hygiene policy confirmed that hand hygiene is required immediately after glove removal and before moving from a soiled to a clean body site on the same resident. The failure to follow these protocols was observed and confirmed through staff interviews and record review.
Failure in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in the improper storage and potential diversion of medications for a resident. The resident, a male with a history of malignant neoplasms of the spinal cord and brain, as well as benign prostatic hyperplasia, was admitted to the facility and had an active order for Morphine Sulfate to manage severe pain. The medication was to be administered every three hours as needed. However, after the resident was discharged to a hospital and subsequently passed away, it was discovered that a card of Morphine tablets and the corresponding narcotic sheet were missing from the medication cart. Interviews and record reviews revealed that the facility did not have a robust system in place to ensure the proper storage and accounting of medications, particularly after a resident's discharge or death. The missing medication was not identified until a Licensed Vocational Nurse (LVN) noticed the absence during a shift change. The LVN reported the discrepancy to the Nurse Manager, who then involved the Interim Director of Nursing (DON) and the Administrator. Despite efforts to locate the missing medication, it was not found, and the facility's procedures for removing discontinued or discharged residents' medications were unclear and inconsistently followed. The investigation highlighted several lapses in protocol, including the failure to remove the deceased resident's medications from the cart in a timely manner and the lack of a system to detect missing medications when both the narcotic sheet and medication card were absent. The facility's policy required controlled medications to be counted at the end of each shift, with discrepancies reported immediately, but this was not effectively implemented. The absence of a clear protocol for handling medications after a resident's discharge contributed to the deficiency, leaving the facility vulnerable to medication diversion and errors in medication administration.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with two medication carts, 4S1 and 4S2, on the fourth floor. On the specified date, these carts were found unattended and unlocked in the dining area, with the locks popped out. RN A, the charge nurse responsible for these carts, admitted to leaving them unlocked while she was administering a COVID test and wound care to a resident. She acknowledged her training on locking the carts when not in direct sight and recognized the potential negative outcomes of her oversight, including unauthorized access to medications. Interviews with the Interim DON and the ADM revealed that staff were trained to lock medication carts when unattended, but there was no awareness of the carts being left unlocked. Both the Interim DON and the ADM emphasized the importance of securing the carts to prevent unauthorized access and potential medication misappropriation. The facility's policy on administering medications requires that medication carts be kept closed and locked when out of sight, which was not adhered to in this instance.
Inadequate Care Plan for Resident's Nutritional and ADL Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which was consistent with the resident's rights and included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The deficiency was identified during a review of care plans for residents, where it was found that the care plan for a resident did not accurately reflect her needs for assistance with activities of daily living (ADLs) and nutritional needs, specifically during meals. The resident, who had several medical conditions including heart failure, psychotic disorder, and severely impaired cognition, required supervision and assistance during meals, which was not adequately documented in her care plan. The care plan for the resident was initiated and revised but failed to accurately capture the resident's need for cuing and supervision during meals, as indicated in her nutritional assessment. Observations during a meal showed that the resident required frequent staff cueing to eat, which was not consistently documented in her care plan. Interviews with facility staff, including the Administrator (ADM), Director of Nursing (DON), and MDS coordinator, revealed that the care plans were developed by the MDS nurse and were supposed to be monitored and updated by the interdisciplinary team. However, the DON and MDS coordinator were unaware that the care plan was not accurate or consistent with the resident's needs. The facility's policy on care plans emphasized the need for comprehensive, person-centered care plans that are updated as resident conditions change. Despite this policy, the care plan for the resident did not reflect her current needs, which could have resulted in inadequate care. The MDS coordinator acknowledged that the care plan should have been updated to reflect the resident's nutritional assessment and need for assistance during meals, highlighting a gap in the facility's care planning process.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with eating to a resident who was unable to perform activities of daily living independently. The resident, a female with severe cognitive impairment and multiple medical conditions, was on in-room isolation and required assistance with meals. On a specific day, the resident did not receive the needed help during lunch and dinner, which could lead to decreased food intake and other health issues. The resident's care plan indicated she required cuing assistance with meals and was on a mechanically altered diet. Despite this, a CNA assigned to the resident on the day in question was not informed of the resident's need for assistance with eating. The CNA delivered meals to the resident's room but did not provide the necessary support, resulting in the resident consuming very little of her meals. Interviews with facility staff revealed a lack of communication and training regarding the resident's needs. The CNA was not aware of the resident's requirements, and the facility's procedure for ensuring dependent residents receive adequate care was not effectively implemented. The facility's policy stated that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, but this was not adhered to in the case of the resident in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whisperwood Nursing & Rehabilitation Center | 0.2 mi | — | 2 | 0 |
| The Plaza At Lubbock | 1.2 mi | — | 9 | 0 |
| Mi Casita Nursing And Rehabilitation Center | 1.7 mi | — | 15 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.7 mi | — | 3 | 2 |
| Mesquite Post Acute Care | 1.8 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.