Carmel Manor
Carmel Manor in Fort Thomas, KY — inspection on March 15, 2025.
Found 3 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
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