Carmel Manor: Resident Left Unmonitored All Night - KY
The family of the resident, identified in inspection records as R24, had installed surveillance in her room. On the morning of March 12, 2025, the resident's daughter, identified as F3, went to the Director of Nursing and said her mother had not been cared for during the night. She had the footage to prove it.
The Director of Nursing confirmed to federal inspectors that F3 told her the video showed R24 left alone all night. The DON notified the administrator, and an investigation began.
The nursing assistant assigned to R24 that night, identified as STNA22, told inspectors he worked the 11:00 PM to 7:00 AM shift on March 11. He said the aide who gave him report at the start of his shift told him R24 had just been changed, so he did not check her brief when he arrived. He said he looked in on her by opening her door enough to see she was in bed, roughly every other hour, but he did not always enter the room, and he did not turn on the lights. During one of those hours, he said, he did go in and checked her brief. When he woke her at approximately 5:15 AM, he found her wet, though he said she was not soaked.
He acknowledged staff were supposed to round once every hour and check and reposition residents every two hours.
The aide who worked the shift before him, SRNA23, told inspectors she rounded on R24 around 6:45 PM but did not provide care at that time. She said she continued rounding until her shift ended at 11:00 PM.
What happened in the hours between is what the video captured.
Inspectors attempted to reach RN6 by phone three times on March 13, leaving a voicemail each attempt. No call was returned.
The Medical Director told inspectors he had been informed about the family's video and that it showed R24 was not monitored by clinical staff through the night. He said it also appeared she had not received any of her evening medications. "Missing a dose or two is not ideal," he said. "I don't believe she was harmed in any way, but it's still not an acceptable situation. I would like to prevent this from happening again."
The Interim Administrator told inspectors she had requested to see the footage herself, and F3 showed her the complete recording. She said she then initiated an investigation and suspended the staff members involved.
CMS rated the violation at minimal harm or potential for actual harm, affecting few residents. The inspection was completed March 15, 2025.
What the records do not resolve is how long R24 had been wet before 5:15 AM, what medications she missed and whether any required consistent timing to be effective, or why the nurse assigned to her floor did not answer three calls from a federal inspector over the course of an afternoon.
Her daughter had to install a camera to find out what was happening to her mother at night. Then she had to walk into the Director of Nursing's office the next morning and show the evidence herself.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
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 violations during a health inspection on March 15, 2025.
The family of the resident, identified in inspection records as R24, had installed surveillance in her room.
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.