Carillon Inc

Inspectors wroteBased on observation, interview, and record review, the facility failed to make information on how to file a grievance or complaint available to the residents for 10 of 10 confidential residents reviewed for grievances. The facility failed to ensure 10 of 10 residents were provided, through postings in prominent locations, the Grievance Procedure, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased 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 facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the garbage can used for food waste was covered unless in use. 3) The DC failed to wear a hair restraint to cover his mustache. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters (dumpsters #1 and #2), in that: -The doors for dumpsters #1 and #2 were left open.-Garbage was left outside of the dumpster. These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased 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 diseases for 3 of 3 residents (Residents #3, #66 and #85) and 2 of 2 (RN A and RN B) staff reviewed for infection control. The facility failed to use EBP during wound care for 3 Residents (Residents #3, #66 and #85). This failure could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 6 residents (Residents #10 and #26) reviewed for advanced directives. The facility failed to ensure Residents #10 and #26 who were listed as DNR (Do Not Resuscitate), had Do Not Resuscitate forms that did not have missed required information. These failures could place residents at risk of not having their end-of-life wishes honored and incomplete records.

Inspectors wroteBased on interview and record review the facility failed to transmit a completed discharge assessment that accurately reflected the residents' status for 1 of 27 sampled residents (Resident #40) whose records were reviewed, in that: Resident #40's Discharge MDS was not transmitted within 14 days of the completed date. This failure could place residents at risk by not receiving the appropriate assessments. Record review of Resident #40's admission Record dated 06/17/2026 revealed an [AGE] year-old female originally admitted to the facility on [DATE] and discharged from the facility on 01/30/2026. Resident #40 had the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 8 percent based on 2 errors out of 25 opportunities, which involved 1 (Resident #81) of 3 residents reviewed for medication administration. RN A failed to give Resident #81's medications according to physician's orders when she administered the medications Amlodipine (for blood pressure) and Losartan Potassium (for blood pressure) outside the ordered vital sign parameters. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and a decline in health. Record review of Resident #81's admission Record dated 06/17/2026 revealed an [AGE] year-old female with an admission date of 03/06/2026. Resident #81 had diagnoses which included: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents and establishes a system of records of receipt and disposition of all drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident reviewed for pharmaceutical services in that: The facility failed to have a system in place to ensure proper storage of medications that would prevent missing medications for Resident #1. This failure could place residents at risk of having their medications diverted and/or receiving the incorrect dosage because of improper storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 6 medication carts (Cart 4S1 and Cart 4S2) observed in the facility. The facility failed to ensure medication cart 4S1 and medication cart 4S2 on the fourth floor were secured when unattended on 2/25/25. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion.

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #1's activities of daily living and nutritional needs, specific to assistance needed during meals. This failure could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 5 residents (Resident #1) reviewed for quality of life. The facility failed to ensure Resident #1 was provided assistance with eating during the lunch meal and dinner meal on 10/12/2024, while the resident was on in-room isolation. This failure could place residents at risk for decreased food intake, weight loss, decline in health, and a decreased quality of life.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 22 residents (Residents #48 and #56) reviewed for care plans as follows: Facility failed to develop a care plan for Residents #48 and #56 for current advanced directives. These failures could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 22 residents (Resident #34) reviewed for PRN psychotropic medications. Resident #34 continued to have a PRN order for Lorazepam 0.5mg after 14 days without a duration. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 6 of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for neglect in that: The ADM and the DON failed to report Resident #1's injuries of unknown origin that were first identified on 01/19/24. [...]

Inspectors wroteBased 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: 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. [...]