Carmel Manor
Carmel Manor in Fort Thomas, KY — inspection on March 15, 2025.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 03/05/2025 at 11:15 AM with the Interim Administrator, she stated her first day at the facility was 02/17/2025, and the previous Administrator was asked to leave not long after that.
She stated she became aware there were several facility-reported incidents that were ongoing, and one involved a resident's ring which had not been reported to the State Survey Agency (SSA) or to the local law enforcement.
She stated she then reported it as soon as she was made aware and made sure staff knew what a reportable incident was and what the regulatory time frames were.
She stated it was her expectation that all reportable incidents be reported timely and as the regulation outlined.
185208 03/15/2025
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
During an interview, with SRNA23, on 03/13/2024 at 4:27 PM, she stated she worked the 7:00 PM to
not provide care at that time.
However, she stated she continued to round on the resident until end of shift at 11:00 PM.
Telephone interview with RN6 was attempted by the SSA Surveyor on 03/13/2025 at 2:27 PM, 2:38 PM, and 3:14 PM. A voicemail was left each time to return the SSA Surveyor's call. No return call was received.
During an interview with the DON, on 03/13/2025 at 11:30 AM, she stated F3 complained on the morning of 03/12/2025, that the resident had not been cared for during the night, and F3 had video surveillance showing R24 was left alone all night.
The DON stated she notified the Administrator, and an investigation was initiated.
She stated R24 should have been checked on at least every two hours.
Further, R24 should have been monitored for pain.
The DON stated it was her expectation that clinical staff rounded on residents throughout the night and that nursing staff provided care for residents as per the CCP.
She further stated following the plan of care was important to provide appropriate, resident-specific care.
During an interview with the Interim Administrator, on 03/15/2025 at 11:46 AM, she stated she was notified of the staff's failure to round on R24 by the DON.
The Interim Administrator stated F3 showed her the complete recording of video footage using the monitoring application on her iPhone.
The Interim Administrator stated she initiated an investigation and suspended the staff members involved.
She stated it was her expectation clinical staff rounded on residents and provided care as ordered and as per the CCP.
During an interview with the Medical Director on 03/13/2025 at 3:08 PM, he stated he was notified about a video from R24's family, which revealed the resident was not monitored by clinical staff throughout the night. He further stated it appeared R24 did not receive any of her evening medications. He stated it was his expectation nursing staff implemented the CCP to ensure the facility maintained the resident's highest practicable level of functioning and well-being.
185208 03/15/2025
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
During an interview, on 03/13/2025 at 11:30 AM, with the Director of Nursing (DON), she stated staff was to follow the facility's fall protocol which included completing the Fall Checklist, which listed each step to complete when a fall occurred.
She stated the checklist was to be completed by the nurse on duty and given to the DON for review at the Interdisciplinary Team (IDT) meeting.
She further stated the IDT would then review the incident and add/revise interventions to prevent future falls. In further interview, she stated she could not find a Fall Checklist for R13's 06/06/2024 fall.
The DON stated she currently kept IDT notes in a binder as they were not part of the EMR.
During an interview with the Interim Administrator, on 03/15/2025 at 11:46 AM, she stated it was her expectation that staff would follow the facility's policies related to falls, and development/revision of care plans for the safety of the residents.
185208 03/15/2025
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
During the next hour, he stated he entered the room and checked R24's brief for wetness.
He stated he was uncertain when R24 went to bed on 03/11/2025 because he did not start his shift until 11:00 PM.
Additionally, STNA22 stated nurses rounded every other hour, checking on residents by opening the doors to ensure everyone was sleeping well. He stated staff members were aware of which residents required more frequent changes, so they were checked on more often. He stated, when he woke R24, he found her wet but not soaked. He stated staff should follow the facility's policy to round once every hour, and then check and reposition the resident every two hours.
During an interview with SRNA23 on 03/13/2024 at 4:27 PM, she stated she worked the 7:00 PM to 11:00 PM shift on 03/11/2025.
She stated she rounded on R24 in her room around 6:45 PM, but she did not provide care at that time.
However, she stated she continued to round on the resident until the end of her shift at 11:00 PM.
A telephone interview with RN6 was attempted by the SSA Surveyor on 03/13/2025 at 2:27 PM, 2:38 PM, and 3:14 PM. A voicemail was left each time to return the SSA Surveyor's call. No return call was received.
During an interview with the Director of Nursing (DON) on 03/13/2025 at 11:30 AM, she stated F3 made a complaint to her on 03/12/2025 in the morning, that her mother had not been cared for during the night.
The DON stated F3 told her that she had video surveillance showing R24 was left alone all night.
The DON stated she notified the Administrator, and an investigation began.
The DON stated it was her expectation that clinical staff rounded on residents throughout the night and that nursing staff provided care for residents as directed to support their highest level of functioning and well-being.
During an interview with the Interim Administrator on 03/15/2025 at 11:46 AM, she stated she was made aware of the staff's failure to round on R24 by the DON.
She stated that she, the DON, and the Nurse Consultant met with R24's family to address their concerns.
The Interim Administrator stated she requested to review the video footage, and F3 showed her the complete recording.
She stated she initiated an investigation and suspended the staff members involved.
She stated that routine rounding was essential for ensuring the well-being and safety of residents, and it was her expectation that clinical staff rounded on residents and provided care as ordered.
During an interview with the Medical Director on 03/13/2025 at 3:08 PM, he stated he was informed about a video from R24's family,which revealed the resident was not monitored by clinical staff throughout the night. He further stated it appeared R24 did not receive any of her evening medications.
The Medical Director stated it was his expectation that such occurrences did not happen in the future. He stated, Missing a dose or two is not ideal. 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.
Additionally, he stated it was his expectation that nursing staff provided resident care as ordered to ensure the facility maintained the resident's highest practicable level of functioning and well-being.
185208 03/15/2025
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
During an interview with the DON on 03/13/2025 at 11:30 AM, she stated gait belts were to be used for all transfers with residents who were not independent.
She stated it was her expectation that staff followed the facility's policy and use gait belts on all residents requiring transfer assistance.
The DON stated this was important for the safety and well-being of the residents. In further interview, the DON stated she was unable to locate IDT notes nor was she able to find an investigation related to R12's 06/07/2024 fall.
- Review of R13's admission Record, located in the resident's EMR, revealed the facility admitted
R13 on 06/29/2023 with diagnoses to include Alzheimer's disease, muscle weakness, and reduced mobility.
Review of R13's CCP, dated 06/29/2023, located in the resident's EMR, revealed R13 was care planned for being at increased risk for falls related to a history of falls.
Interventions included keeping the resident's call light in reach, encouraging the resident to participate in activities, ensuring the resident was wearing appropriate footwear, and following fall protocol.
Review of R13's Occurrence History report provided by the facility, revealed she had one fall on 06/09/2024 resulting in a minor injury, and four non-injury falls on 07/17/2024, 09/06/2024, 02/25/2025, and 03/09/2025.
Furthermore, a witnessed non-injury fall, on 03/04/2024, was not noted on this report.
Review of R13's Fall Checklist, provided by the facility and dated 02/25/2025 at 4:02 AM, revealed an intervention to initiate an [TRUNCATED]
185208 03/15/2025
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
During an interview with the Medical Director on 03/13/2025 at 3:08 PM, he stated he was informed about a video from R24's family, which revealed R24 was not monitored by clinical staff throughout the night. He stated it appeared R24 did not receive any of her evening medications.
The Medical Director stated it was his expectation that such occurrences did not happen in the future. He stated, Missing a dose or two is not ideal. 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.
Additionally, he stated it was his expectation that nursing staff provide resident care as ordered to ensure the facility maintained the resident's highest practicable level of functioning and well-being.
185208 03/15/2025
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
During a telephone interview with the Medical Director on 03/13/2025 at 3:08 PM, he stated it was his expectation for staff to follow the facility's policy to help prevent the spread of infections.
The Medical Director stated it was important to prevent the spread of disease and infection and for the health and safety of the residents.
F-F656.
The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/12/2025, alleging removal of the IJ on 03/10/2025.
The State Survey Agency (SSA) validated the IJ was removed on 03/15/2025, prior to exit.
Remaining non-compliance continues at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes.
Refer to
Review of the facility's policy titled, Elopements and Wandering Residents, dated 04/18/2024, revealed the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents.
The policy further stated residents received care in accordance with their person-centered care plan of addressing their unique factors contributing to wandering or elopement risk.
Per policy, the facility was equipped with door locks/alarms to help avoid resident elopements, but alarms were not a replacement for necessary supervision.
Further review revealed devices used to prevent elopement were checked for functionality and placement, and this would be documented every shift on the Treatment Administration Record (TAR).
The policy stated a system would be in place for systematic and frequent checks of all critical components of the electronic alarm system with clear designation of responsibility for monitoring and maintaining the system.
Per policy, a basic check of the system was to be done every 24 hours to assure proper functioning.
Additionally, the policy stated maintenance of the system must be consistent with the manufacturer's guidelines, and a complete systems check must be performed at least annually.
Review of the website's manual (found at https://jmacfiles.s3.amazonaws. com/docs_Roam_Alert_User_Guide.pdf) RoamAlert Resident Safety User Guide, dated 01/2010, revealed monthly testing and maintenance was essential to ensure the program was operating correctly. It also stated the failure to do regular testing and maintenance would increase the risk of system failure and the failure to detect resident wandering.
The State Survey Agency (SSA) Surveyor requested the log of the wanderguard system/electronic alarm system checks from the Maintenance Director on 03/05/2025 at 3:28 PM and from the Interim Administrator on 03/06/2025 at 9:07 AM and 03/07/2025 at 8:30 AM.
However, the log was not provided.
Review of the facility's document titled, Service Orders for [Facility Name] Nursing Home, dated 02/26/2025 to 03/07/2025, revealed the vendor for the wanderguard system had serviced the facility on 02/26/2025 to reprogram the RoamAlert/wanderguard keypad passcode; on 02/28/2025 for wanderguard not recognizing when someone went through the door; on 03/06/2025 for wanderguard alarming on its own; and on 03/10/2025 to confirm the order for two new door controllers.
Review of the Weather underground.com temperature history for the facility area on 02/25/2025, revealed a temperature of 65 degrees Fahrenheit from 3:30 PM until 5:30 PM.
Review of R1's Admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted R1 on 04/16/2024 with diagnoses including mild cognitive impairment/severe vascular dementia with agitation, moderate malnutrition, and need for assistance with personal care. On 09/05/2024, R1 was diagnosed with wandering.
Per the EMR, the resident resided on the locked MCU.
185208
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185208 B.
Wing 03/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
F-F689, and Substandard Quality of Care (SQC) at 42 CFR 483.25.
185208
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185208 B.
Wing 03/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Carmel Manor 100 Carmel Manor Road Fort Thomas, KY 41075
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.