Cycle 1
Health 2025-04-25 · Fire 2025-04-25
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lubbock, TX
Carillon Inc
3-star overall rating with 3-star inspections with $58,719 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1717 A Norfolk Ave, Lubbock, TX
(806) 281-6114
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-12-17
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.88
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.38
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
5.34
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,256
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0049
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.79% · Performance 21.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
10
Baseline 4.31% · Performance 4.91% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
1.65
Baseline 35.71% · Performance 56.93% · Measure score 1.65 · Achievement 1.65 · Improvement 0
Adjusted total nurse staffing
8.62
Baseline 4.80 hours · Performance 5.53 hours · Measure score 8.62 · Achievement 8.62 · Improvement 6.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.96% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 387 · Observed rate 9.82% · Lower 95% interval 8.38% |
| Discharge to community | 53.55% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 359 · Observed rate 49.58% · Lower 95% interval 48.52% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.41% |
95.27%
3.1 pts better
|
Numerator 186 · Denominator 189 |
| Falls with major injury | 1.06% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 189 |
| Discharge self-care score | 44.93% |
53.69%
8.8 pts worse
|
Numerator 62 · Denominator 138 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 46 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 3 · Denominator 189 · Adjusted rate 1.88% |
| Healthcare-associated infections requiring hospitalization | 4.91% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 181 · Observed rate 2.21% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 3.31% |
8.2%
4.9 pts worse
|
Numerator 8 · Denominator 242 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 72 · Denominator 138 |
| Transfer of health information to provider | 92.74% |
95.95%
3.2 pts worse
|
Numerator 115 · Denominator 124 |
| Transfer of health information to patient | 72.73% |
96.28%
23.5 pts worse
|
Numerator 32 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 22.11% |
25.2%
3.1 pts worse
|
Numerator 21 · Denominator 95 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 0.8 · Expected 0.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.1
1.6 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.3 · Expected 1.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
97.1%
0.4 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 90.3% · Q3 96.4% · Q4 100.0% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
97.9%
5.5 pts worse
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.1% |
3.3%
5.8 pts worse
|
3.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.3% · Q3 7.3% · Q4 6.9% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
2.7%
1.6 pts worse
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 10.2% · Q3 1.9% · Q4 3.4% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
3.3%
2.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
18.9%
2.8 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 13.3% · Q3 7.1% · Q4 30.2% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
10.8%
1.3 pts worse
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 5.9% · Q3 8.8% · Q4 12.9% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.8% |
15.4%
9.4 pts worse
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 20.6% · Q4 31.4% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.4% |
16.1%
15.3 pts worse
|
14.9%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 35.7% · Q3 7.7% · Q4 48.8% · 4Q avg 31.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.5%
0.7 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.5% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.8%
0.5 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
15.0%
9.1 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 27.9% · Q3 20.8% · Q4 22.8% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.2%
2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 2.0% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
89.7%
5.7 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 92.4% · Q3 92.4% · Q4 98.2% · 4Q avg 95.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
12.0%
5.1 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.7% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.4% · Q3 0.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
88.0%
2.2 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.5% |
25.9%
7.6 pts worse
|
23.9%
9.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.5% · Observed 31.7% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-04-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-10
F · Potential for more than minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-25
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-02-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-10-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-03-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-22
K · Immediate jeopardy
2024-01-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-19
D · Potential for more than minimal harm
2023-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-02-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-09
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-09
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-06
Penalties and ownership
What sits behind the stars
$57,321
2024-01-27
Fine
Fine · fine $57,321
Fine
$1,398
2023-05-30
Fine
Fine · fine $1,398
Fine
Ownership
Carillon, Inc.
5% Or Greater Direct Ownership Interest · Organization
Breedlove, Billy
Corporate Director · Individual
Culberson, John
Operational/Managerial Control · Individual
Fulton, Kyle
Corporate Director · Individual
Hatch, Leslie
Corporate Director · Individual
Klein, Trenton
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Owens, John
Corporate Director · Individual
Powell, Dianne
Corporate Director · Individual
Roddy, Pamela
Operational/Managerial Control · Individual
Skinner, Derek
Operational/Managerial Control · Individual
Turner, Lane
Corporate Director · Individual
U.s. Bank
5% Or Greater Security Interest · Organization
Wilkerson, David
Corporate Director · Individual
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#3
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