Carmel Manor: Immediate Jeopardy for Abandoned Resident - KY
A resident at Carmel Manor, identified in federal inspection records only as R24, spent an entire night without being checked on, repositioned, monitored for pain, or given her evening medications. The footage, captured on a home monitoring system and reviewed through a family member's iPhone, showed no clinical staff entering the room from the time the evening shift began until morning.
The family member, identified in the report as F3, brought the recording directly to the Director of Nursing on the morning of March 12, 2025. The DON confirmed she watched it. So did the Interim Administrator.
Federal inspectors, who arrived at Carmel Manor on March 15, 2025, classified the failure as immediate jeopardy, the most serious level of harm under Medicare and Medicaid oversight, meaning the neglect placed the resident's health or safety at serious risk.
R24's care plan required staff to check on her at minimum every two hours through the night. The Medical Director told inspectors he believed she had not received any of her evening medications. He said he learned about the situation after the family's video surfaced.
The night shift in question ran from 7:00 PM to 11:00 PM, covered in part by a nursing assistant identified as SRNA23. She told inspectors she had rounded on R24 at around 6:45 PM but did not provide care at that time. She said she continued to check on the resident through the end of her shift at 11:00 PM. The video told a different story.
A second nursing assistant, STNA22, told inspectors he checked on R24 and repositioned her every two hours and that nurses also rounded every other hour, opening doors to make sure residents were sleeping. Inspectors noted his account without reconciling it against the footage.
The nurse on duty that night, identified as RN6, did not speak with inspectors. Surveyors called three times on March 13, leaving a voicemail each time. No call was returned.
The DON told inspectors the investigation began the morning F3 came forward. The Interim Administrator confirmed she suspended the staff members involved after reviewing the full recording. Both said their expectation was that staff round on residents through the night and follow each resident's individual care plan. Neither offered an explanation for why that hadn't happened.
The Medical Director said his expectation was the same: that nursing staff follow the care plan to maintain each resident's highest level of functioning and well-being. He did not explain what he intended to do about the missed medications.
R24's condition and what the night without care cost her are not detailed in the inspection report. What is documented is that she was in her bed, that she sometimes tried to crawl out, and that nobody came.
The inspection was completed March 15, 2025. F3 had been carrying the footage for three days by then.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carmel Manor from 2025-03-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
Carmel Manor in Fort Thomas, KY was cited for immediate jeopardy violations during a health inspection on March 15, 2025.
The family member, identified in the report as F3, brought the recording directly to the Director of Nursing on the morning of March 12, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.