Carmel Manor

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

F-F657

The findings include:

1. 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 Resident R1's Admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted Resident 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, Resident R1 was diagnosed with wandering. Per the EMR, the resident resided on the locked MCU.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of Resident R1's Comprehensive Care Plan (CCP), dated 05/20/2024, located in the resident's EMR, revealed Resident R1 was an elopement risk/wanderer related to impaired safety awareness and wandered aimlessly. The goal Level of Harm - Immediate stated Resident R1 would not leave the facility unattended. Interventions included resident to wear wanderguard to his jeopardy to resident health or right wrist and for the nurse to check placement each shift. safety

Review of Resident R1's Clinical Orders, dated 05/20/2024 and 01/31/2025, located in the resident's EMR, revealed Residents Affected - Few orders for Resident R1 to wear a wanderguard bracelet to his right wrist and to check every shift.

Review of Resident R1's Progress Notes, from 04/16/2024 to 02/25/2025, revealed instances where Resident R1 had been noted to be wandering and required redirection. These dates included: 04/19/2024, 04/26/2024, 06/25/2024, 06/30/2024, 09/04/2024, 09/05/2024, 09/06/2024, 09/09/2024, 09/16/2024, 11/13/2024, and 01/21/ 2025.

Review of Resident R1's Progress Note, dated 06/25/2024 at 3:44 PM, revealed Resident R1 was exit-seeking, went outside

the exit door, and was brought back into the facility immediately. However, per the note, the wanderguard was not on his right wrist, and Resident R1 stated he lost it at some point during the night. The note stated a new wanderguard was applied to Resident R1's right wrist and checked to ensure it was working properly. Further review revealed an order was in place to ensure the wanderguard was checked each shift.

Review of Resident R1's Elopement Risk Assessment, dated 01/23/2025, revealed a score of seven which indicated

he was at high risk for elopement. Per the legend, any score above three was considered high risk.

Review of Resident R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/2025, located in the resident's EMR, revealed the facility assessed Resident R1 to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating moderate cognitive impairment. Further review revealed the facility assessed the resident to have wandered one to three days during the look back period.

Review of Resident R1's Treatment Administration Record (TAR), dated 02/2025, located in the resident's EMR, revealed the placement of Resident R1's wanderguard had been charted as checked and charted as present on 02/25/2025 on day shift by Licensed Practical Nurse (LPN) 1. However, there was no documented evidence

a check of functionality had been completed.

Review of Resident R1's Progress Note, dated 02/25/2025 at 11:05 PM, signed by the MDS Nurse, located in the resident's EMR, revealed Resident R1 had followed visitors through the exit doors on the MCU, exited the facility for a short time, and returned through the front doors. Per the note, Resident R1 told the receptionist he needed to sign back in, and he was out looking for his dog. The receptionist recognized the resident and assisted the resident back to the locked MCU. The note stated the nurse completed a head-to-toe assessment with no injuries noted. Per the note, Resident R1 had no complaints of pain with touch and vital signs were within normal range. The note stated Resident R1 was placed on one on one (1:1) observation for safety, and Resident R1's family was in the facility and was given notification.

Observation on 03/05/2025 at 12:10 PM, revealed Resident R1 was ambulating independently with his son and entered the facility through the main doors. Resident R1's wanderguard was visible on his right wrist, and the alarm was sounding as he entered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Observation on 03/05/2025 at 12:13 PM, revealed Resident R1 was in his room, in bed. Resident R1 stated he wore a wristwatch and this other one, while pointing at the wanderguard. Resident R1 denied knowing the purpose of the Level of Harm - Immediate wanderguard bracelet. jeopardy to resident health or safety During an interview, on 03/05/2025 at 12:19 PM, with Resident R1's Power of Attorney (POA), he stated the facility notified him of the resident leaving the facility unaccompanied on 02/25/2025, within 30 minutes of the Residents Affected - Few resident returning to the facility. He further stated he understood Resident R1 had returned on his own, walked through

the facility's front door, and signed himself in as Me. Resident R1's POA stated no harm had come to Resident R1, and he was not sure if Resident R1's wanderguard was in place the last time he visited. He further stated, It was like a wristwatch, and I just got used to seeing it on him. In continued interview, Resident R1's POA stated the facility told him Resident R1 was not wearing the wanderguard when he returned to the facility, and to his knowledge, the facility had not been able to locate it. He stated he asked Resident R1 what happened to it, and Resident R1 told him he was in the field and a girl had cut it off. Resident R1's POA stated he observed staff replacing the wanderguard while he was visiting Resident R1.

During an interview, on 03/06/2025 at 2:35 PM, with State Trained Nurse Assistant (STNA) 1, he stated he had worked at the facility since 04/02/2024 and was assigned to Resident R1 the day he eloped. STNA1 stated the last time he remembered seeing Resident R1 was about 3:45 PM to 4:00 PM that day in the Common Room, and after that, he was giving another resident a shower and did not hear any alarms sounding on the unit. STNA1 stated he was made aware Resident R1 was returning to the unit on the elevator and did not recall specifically seeing

a wanderguard on Resident R1, but if Resident R1 had come within about six feet of the door, it would have alarmed. STNA1 stated the alarm was loud and audible over the whole unit, but since he was in the shower room with another resident he might not have heard it sound. STNA1 also stated the alarm for the side fire door off the unit and next to the elevators was also very loud, and he was able to hear it on the memory care unit if it sounded.

During an interview, on 03/06/2025 at 2:49 PM, with Licensed Practical Nurse (LPN)1, she stated she had worked at the facility since 03/13/2006 and was assigned to Resident R1 on the day he eloped. LPN1 stated the last time she saw Resident R1 was around 4:00 PM in the Common Room where the residents were listening to music and watching television. LPN1 stated she received a readmission from the hospital at about 4:15 PM and was providing care for that resident in the resident's room, and did not hear any alarms sound on the unit during that time. LPN1 stated she received a call from Receptionist 2 and was told Resident R1 was returning to the facility alone through the front entrance, and she would assist him to the elevator and send him down to the MCU. LPN1 stated that happened around 5:00 PM to 5:15 PM, and she knew that because supper meal trays were out. In continued interview, LPN1 stated there was an order to check the placement of Resident R1's wanderguard every shift. She stated she checked the placement of Resident R1's wanderguard on 02/25/2025, and it was on his wrist, but she could not remember the exact time she checked the wanderguard for placement. LPN1 stated when a resident with a wanderguard got close to the door, it would alarm, but not too loud, then it would beep for about 30 seconds, and then would turn off by itself. LPN1 stated there was no code for staff to shut

the alarm off.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During continued interview with LPN1, on 03/06/2025 at 2:49 PM, she stated Resident R1 had previously complained his wanderguard was too tight, but he had not complained about it on 02/25/2025 or the day before and she Level of Harm - Immediate had never cut his wanderguard off. LPN1 stated a new one had been placed on Resident R1 when he returned to the jeopardy to resident health or unit on 02/25/2025. LPN1 stated she asked Resident R1 where his wanderguard was when he returned and he stated, safety I took it off and threw it. LPN1 stated the staff searched the unit, Resident R1's room, and the garbage, but could not find the missing device. She stated prior to Resident R1 eloping, she checked the function of the residents' Residents Affected - Few wanderguard devices weekly by pushing the resident's wheelchair near to or walking the resident up near

the door and making sure the alarm would sound. LPN1 stated she did not have a wand or device to test the wanderguard alarm on the unit. Further, she stated she did not document checking the function of the residents' wanderguard. LPN1 stated the day Resident R1 eloped, it was supper time, the television was on, the music was loud, and since she was in a room with another resident, she did not hear any alarms go off. LPN1 further stated the double doors to the MCU had a delay in closing.

During an interview, on 03/05/2025 at 3:28 PM, with the Maintenance Director, he stated he had been at the facility for [AGE] years and had reviewed the facility's video footage of the front door. He stated he observed Resident R1 coming back to the facility through the front door but was not able to identify him leaving the facility through the front door. He further stated the camera was situated to record the main entrance between the outside door and the locked facility door in the vestibule. He also stated it was difficult to tell Resident R1 from other visitors, and he might have been able to follow a group of visitors out the front door. The Maintenance Director stated none of the staff heard an alarm go off around the time Resident R1 left the facility, and therefore thought Resident R1 must have tailgated with the visitors out the double doors of the MCU, rode the elevator up to the main floor, and then exited out the front door. The Maintenance Director stated prior to Resident R1 leaving the facility unattended, family members were given the code to the locked double doors to the MCU and could come and go without staff assistance. Further, he stated that since the incident, the codes to the doors had been changed and were given to staff only.

During an interview, on 03/05/2025 at 3:52 PM, the Interim Administrator stated she had been at the facility since 02/17/2025, and the Director of Nursing (DON) stated she had been at the facility for eight weeks.

They both stated they felt Resident R1 had followed visitors out the locked double doors to the MCU and then exited out the side fire door next to the gated garden area near Elevators 6 and 7. The Interim Administrator stated

she was new to the facility and had only been in the facility for a week when Resident R1 eloped. She stated if she had been aware family members and visitors had the code to the locked MCU doors, she would have had

the codes changed sooner. The Interim Administrator further stated the facility's investigation revealed Resident R1's elopement happened right before supper service, during a time when a resident activity was happening which often included a movie or music, and staff did not hear the side fire door alarm when Resident R1 left. Additionally, the Interim Administrator stated Emergency Medical Services (EMS) was in the building at the time Resident R1 eloped which added to the traffic/activity on and off the unit. The Interim Administrator stated the codes to all the locked doors had been changed, and a letter went out to the residents' families explaining

the need for the doors to stay locked and the need for the codes to be changed. The Interim Administrator stated going forward, staff would have to assist visitors in and out of the facility. The Interim Administrator further stated her plan was to have a telephone/intercom system installed outside the MCU double doors to replace the push pad so visitors would have to call into the unit for entry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In additional interview, with the Interim Administrator, on 03/06/2025 at 9:07 AM, she stated the contractor/vendor for the wanderguard sensors was contacted on 02/26/2025, for a system check, to Level of Harm - Immediate evaluate the alarm and how it responded when the wanderguard bracelet was near it. She stated, on jeopardy to resident health or 02/28/2025, the contractor/vendor found the main wanderguard unit, which was housed in the ceiling just safety inside the double doors to the MCU near the nurses' station, was not receiving information from the exciter sensors. The Interim Administrator stated the other control boxes for the other facility doors were functioning, Residents Affected - Few but not the one for MCU, and the unit would need to be replaced.

In further interview, on 03/06/2025 at 5:30 PM, with the Interim Administrator and the DON, they stated the MCU was a very busy unit, especially at the time of day Resident R1 eloped. They stated often the Common area was full of residents and staff engaged in activities, music and/or watching television, and it could be loud. The Interim Administrator stated depending on the time of day and the environment, alarm audibility could vary.

The Interim Administrator stated going forward, the function of the residents' wanderguards was to be checked every day, and placement of the residents' wanderguards was to be checked every shift and charted on the MAR/TAR and in the Progress Notes.

Observation on 03/13/2025 at 9:57 AM, revealed Resident R1 was sitting at a table in the MCU Common area with staff in the general area. STNA14, the staff person assigned to Resident R1 as his 1:1 monitor for today, was observed in Resident R1's room sitting in the recliner on her phone (at the opposite corner of the unit and out of eyesight/earshot of Resident R1) The Interim Administrator was rounding on the MCU and was made aware by the SSA Surveyor.

During an interview, on 03/13/2025 at 10:05 AM, with STNA14, she stated she had been educated related to elopement and 1:1 observation and was expected to have eyes on Resident R1 at all times. STNA14 further stated

she had just gone back to Resident R1's room to get her phone, and she had told RN4 and STNA15 she was going there and asked them to keep eyes on Resident R1.

During an interview, on 03/13/2025 at 10:09 AM, with RN4, she denied STNA14 telling her she was going to Resident R1's room or asking her to keep eyes on Resident R1.

During an interview, on 03/13/2025 at 10:15 AM, with STNA15, she stated she had not been told to watch Resident R1 while STNA14 went to Resident R1's room. She further stated she had told STNA14 not to leave Resident R1 unattended on two other occasions and had made LPN1 and the Weekend Supervisor aware.

During a telephone interview, on 03/14/2024 at 4:20 PM, with the Weekend Supervisor, she denied being made aware by any staff that STNA14 was observed leaving Resident R1 unattended while she was responsible for his 1:1 observation.

During an interview, on 03/15/2024 at 1:05 PM, with LPN1, she stated to be a 1:1 sitter meant the staff person had eyes on the resident at all times, and if they needed a break, she would have the resident sit with her in the Common area. LPN1 denied any staff ever told her STNA14 left Resident R1 unsupervised.

During an interview with RN1, on 03/13/2025 at 10:25 AM, he stated STNA14 was being escorted out of the building at this time, and RN4 had been told to keep eyes on Resident R1 while Resident R1 was in the Common area. RN1 stated he was told if Resident R1 got up to leave the Common area, either RN4 or STNA15 were to accompany Resident R1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 03/14/2025 at 12:09 PM, RN1 accompanied the SSA Surveyor to the second floor unit, on the [NAME] Unit, and activated the wanderguard alarm on the second floor near the entrance/exit to the unit. An audible Level of Harm - Immediate alarm sounded for 41 seconds with no staff response. The alarm silenced with no staff entry of a code. After jeopardy to resident health or a second immediate activation and after the alarm sounded for 10 seconds, a staff member was overheard safety to ask, What is that sound? Then, per observation, a second staff person answered, That's the door. The audible alarm sounded for an additional 67 seconds, with no staff response. The total alarm time was 77 Residents Affected - Few seconds, with no staff [LPN4 or STNA19] response.

Interview was conducted, on 03/14/2025 at 2:15 PM, with LPN4, who had been employed by the facility for [AGE] years and STNA19, who had been employed by the facility for two years, and they both stated they only had one resident on the unit that used a wanderguard on the [NAME] unit. They stated, if the alarm went off and they had eyes on her, they did not worry about the alarm. LPN4 and STNA19 also stated it was not always easy to hear alarms in the back hall.

Observation and interview with STNA17, on 03/15/2025 at 10:00 AM, on the MCU, revealed STNA17 was assigned 1:1 monitoring for Resident R1 and was posted outside Resident R1's room with eyes on him. STNA17 stated she had received continued education on elopement, missing resident, and additional information on the response to alarms yesterday and this morning.

During interview on 03/15/2025 at 10:05 AM, with STNA18, who was monitoring the entry doors to the MCU,

he stated he had received education on elopement, a missing resident, and response to alarms.

During interview on 03/15/2025 at 10:24 AM, with LPN5, on the [NAME] Unit, located on the second floor,

she stated she received education on elopement and new education

During interview on 03/15/2025 at 10:26 AM, with RN1, he stated there was a whole house test yesterday on door alarms and wanderguards, and the policy was reviewed. RN1 also stated all the alarms on all the units had been made louder.

During interview on 03/15/2025 at 12:00 PM, with the Interim Administrator and the DON, they stated it was their expectation the facility would have an elopement and wandering system in place with immediate staff response, a head count of residents completed, and for staff to report to a manager/supervisor on duty when concerns occur, to ensure resident safety. Further, the DON stated the facility should have been checking placement and functionality of the resident's wanderguards and documenting both in the resident record and

the system functionality should have also been checked regularly and documented.

44001

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the facility's Fall Prevention Program policy, undated, revealed each resident would be assessed for fall risk, and care and services would be provided according to each resident's individualized level of risk Level of Harm - Immediate to minimize the likelihood of falls. Per policy, fall risk protocols included to implement environmental jeopardy to resident health or interventions that decreased the risk of falling; provide routine rounding; wear footwear with non-slip soles safety while ambulating (residents); complete a fall risk assessment upon admission, quarterly, and as indicated for significant condition changes or after each fall; and provide interventions that addressed risk factors as Residents Affected - Few directed by the resident's assessment. Further review revealed when a resident fell , the facility would assess them, complete a post-fall assessment, and generate an incident report. The policy stated the physician and family would be notified, and the care plan would be updated as needed. Per policy, all actions would be documented, witness statements collected if there was an injury, and the interdisciplinary team (IDT) would review the interventions and conduct a complete investigation.

2. Review of the facility's Use of Gait Belts policy, undated, revealed gait belts were to be used for any resident who could not independently walk or transfer, ensuring their safety. Additionally, per policy, all employees received training on the proper use of gait belts during their orientation and annually.

Review of Resident R12's Admission Record, located in the resident's EMR, revealed the facility admitted the resident

on 10/23/2023 with diagnoses to include myasthenia gravis (neuromuscular disorder causing muscle weakness), transient cerebral ischemic attack (mini stroke) and type 2 diabetes.

Review of Resident R12's CCP, dated 10/24/2023, located in the resident's EMR, revealed Resident R12 was care planned for being at increased risk for falls related to impaired mobility and a self-care performance deficit. Interventions included keeping the resident's call light within reach and follow fall protocols.

Review of Resident R12's quarterly MDS with an ARD of 04/09/2024, located in the resident's EMR, revealed the facility assessed Resident R12 to have a BIMS score of nine out of 15, which indicated moderate cognitive impairment. Further review revealed the resident was assessed as not having any falls during the look back period. Continued review revealed the facility assessed Resident R12 as requiring substantial/maximum assist (helper did more than half of the effort) for transfers.

Review of Resident R12's Health Status Note, dated 06/07/2024 at 10:46 PM, located in the resident's EMR, revealed at approximately 8:00 PM, Resident R12 was sitting in the living room recliner when STNA12 assisted her into a wheelchair. During the transfer, Resident R12 fell , landing on top of STNA12. Per the note, the resident sustained three injuries: a wound on the left knee, a wound on the left arm, and bruising with scratches on the left ribcage. The note further stated Resident R12 reported pain at an intensity of eight out of 10 on a pain scale with 10 being the worst. Resident R12 was transported to the local hospital.

Review of Resident R12's Incident Report, dated 06/07/2024 at 8:47 PM, revealed STNA12 acknowledged he did not use a gait belt when transferring Resident R12 from the recliner to her wheelchair. Per the report, STNA12 stated it was an accidental fall, and he attempted to break the fall with his own body. According to the report, Resident R12 leaned back into him, causing him to lose his balance and fall backward, with the resident landing on top of him.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of Resident R12's ED Provider Notes, dated 06/08/2024 at 7:52 AM, located in the resident's EMR, revealed Resident R12 presented to the local ED after a fall. Per the note, Resident R12 complained of chest wall and back pain and a Level of Harm - Immediate skin tear to the right arm. jeopardy to resident health or safety Review of Resident R12's Computed Tomography (CT) (x-ray imaging) of the Chest, dated 06/08/2024 at 7:11 AM, located in Resident R12's EMR, revealed an age-indeterminate nondisplaced left 8th rib fracture. Residents Affected - Few Additional review of Resident R12's CCP, dated 10/24/2023, located in the EMR, revealed Resident R12's care plan was updated on 06/08/2024 to state the resident required extensive assistance by two staff to move between surfaces; however, the CCP was not revised to include transfer using a gait belt.

Review of the facility's Schedule, for 06/07/2024, at the time of Resident R12's fall, revealed the unit where Resident R12 resided was fully staffed with one nurse and two STNAs, and STNA13 was orienting STNA12

The nurse on duty the evening of Resident R12's fall was no longer an employee at the facility.

During an interview with Human Resources (HR), on 03/12/2024 at 8:35 AM, she stated on 06/07/2024, STNA12 was on orientation in the facility and was shadowing STNA13. She stated STNA12 should not have been left alone to provide care.

The State Survey Agency (SSA) Surveyor attempted a telephone interview with STNA13, on 03/12/2025 at 9:04 AM and 9:07 AM, with no success, and a voicemail could not be left.

The SSA Surveyor attempted a telephone interview with STNA12, on 03/12/2025 at 9:05 AM, with no success, and a message stated the phone number dialed did not have voicemail set up.

During an interview with STNA11 (agency), on 03/11/2024 at 10:55 AM, she stated it was the facility's policy to use a gait belt with all residents who required assistance with transfers.

During an interview with STNA20, on 03/13/2025 at 2:35 PM, she stated she used a gait belt for all resident transfers.

During an interview with the Infection Prevention and Staff Development Coordinator (IP/SDC), on 03/12/2024 at 10:30 AM, she stated employees received education upon hire, which included training for safe resident transfers. She stated STNAs did not receive gait belt training during the facility's orientation, as

this training was part of their nursing aide course curriculum. Additionally, the IP/SDC stated staff members received orientation on the floor and were paired with a senior staff member for preceptorship. She stated new employees completed a checklist during that orientation, which the preceptor and employee were required to sign. She further stated it typically took three to four days to finish the checklist. Further, while being oriented on the floor, new hires were not allowed to perform resident care independently. She stated

she did not know why STNA12 independently transferred Resident R12. The IP/SDC stated it was her expectation that staff followed facility policy in an attempt to prevent falls and used gait belts for all assisted transfers to ensure resident and staff safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 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 Level of Harm - Immediate facility's policy and use gait belts on all residents requiring transfer assistance. The DON stated this was jeopardy to resident health or important for the safety and well-being of the residents. In further interview, the DON stated she was unable safety to locate IDT notes nor was she able to find an investigation related to Resident R12's 06/07/2024 fall.

Residents Affected - Few 3. Review of Resident R13's Admission Record, located in the resident's EMR, revealed the facility admitted Resident R13 on 06/29/2023 with diagnoses to include Alzheimer's disease, muscle weakness, and reduced mobility.

Review of Resident R13's CCP, dated 06/29/2023, located in the resident's EMR, revealed Resident 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 Resident 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 Resident R13's Fall Checklist, provided by the facility and dated 02/25/2025 at 4:02 AM, revealed an intervention to initiate an exercise program for gait training was documented; however, the intervention was not added to the CCP.

Review of Resident R13's Fall Checklist, provided by the facility and dated 03/04/2025 at 6:10 PM, revealed there was no initiated intervention added to the CCP after Resident R13 experienced a non-injury fall.

Further review of Resident R13's EMR revealed no documented evidence th [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or 44001 potential for actual harm Based on interview, record review, and review of the facility's policies, the facility failed to ensure that Residents Affected - Few residents who required pain management were provided such services, for 1 of 33 sampled residents, Resident (R) 24.

Review, on 03/14/2025 at 3:35 PM, of a surveillance video of Resident R24, provided by the family, revealed the resident in her room. The video confirmed the last staff member left Resident R24's room at 6:03 PM on 03/11/2025 and re-entered the resident's room at 5:14 AM on 03/12/2025. During this time, Resident R24 was not administered her scheduled pain medication or assessed for signs and symptoms of pain.

The findings include:

Review of the facility's policy titled, Pain Management, undated, revealed the facility must ensure that pain management was provided to residents who required such services consistent with professional standards of practice and the comprehensive person-centered care plan (CCP). Furthermore, the facility must ensure that residents' pain was regularly assessed.

Review of the facility's policy titled, Administration of Medication, undated, revealed medications were administered as ordered by the physician in accordance with professional standards of practice.

Review of Resident R24's Admission Record, found in the electronic medical record (EMR), revealed the facility admitted Resident R24 on 07/02/2024 with diagnoses that included Parkinson's disease, spondylosis (degeneration of

the vertebral column), and spinal stenosis (narrowing of the spaces in the spine) with sciatica (pain along the sciatic nerve).

Review of Resident R24's Quarterly Minimum Data Set [MDS], found in Resident R24's EMR, with an Assessment Reference Date (ARD) of 01/28/2025, revealed Resident R24's Brief Interview for Mental Status [BIMS] was not assessed. However, the facility assessed Resident R24's mental status as short and long-term memory problems.

Review of Resident R24's Physician Orders, found in Resident R24's EMR, revealed the facility admitted Resident R24 to Hospice (end-of-life) care on 01/16/2025. The physician ordered several pain medications that included: tramadol HCl 50 milligrams (mg), one tablet by mouth, scheduled three times a day for pain/comfort; tramadol HCl 50 mg, one tablet by mouth, every six hours as needed for signs and symptoms of pain; acetaminophen 500 mg, two tablets by mouth at bedtime for chronic pain; Salonpas external pain relief patch 3-10%, apply to lower back topically one time a day for intervertebral disc degeneration and back pain, and diclofenac sodium external gel 1% topically for right hip and sacral pain. Further review revealed nursing staff were required to perform and document monitoring and assessments for Resident R24. This included interviewing and observing for signs and symptoms of pain every shift, monitoring behavior every shift, and checking for non-purposeful facial movements (such as lip puckering, frowning, or irregular eyebrow movement) and non-purposeful irregular body movements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Review of Resident R24's Comprehensive Care Plan [CCP], undated, revealed the facility care planned the resident as at risk for alteration in comfort and pain. Goals included Resident R24 would be free of any discomfort or adverse Level of Harm - Minimal harm or side effects from pain medication; Resident R24 would be given the pain medication as ordered, would be monitored, potential for actual harm and the effectiveness of the pain medication and all interventions would be documented; and any unrelieved pain or condition change would be reported to the primary care provider. Residents Affected - Few

Review of Resident R24's Medication Administration Record [MAR], dated 03/2025, revealed Registered Nurse (RN) 6 documented she administered Resident R24's 9:00 PM medications at 9:21 PM. Scheduled 9:00 PM medications included: acetaminophen 500 mg for pain; Carbidopa-Levodopa 25-100 mg for Parkinson's; trazodone HCl 50 mg for primary insomnia; Depakote sprinkles 125 mg for anxiety and restlessness related to dementia; Salonpas external pain relief patch 3-10% for intervertebral disc degeneration and back pain; diclofenac sodium external gel 1% for right hip and sacral pain; tramadol HCl 50 mg for pain/comfort; and Calmoseptine external ointment 0.44-20.6 % for buttocks/coccyx redness. Continued review of the MAR revealed RN6 documented Resident R24's pain level at 0 (having no pain), during the shift.

During a telephone interview with Family (F) 3 on 03/13/2025 at 9:37 AM, she stated she was Resident R24's Power of Attorney (POA). She stated she had some concerns regarding Resident R24's care. F3 stated, up until this point,

the staff had generally been good, but her interactions were mostly with the dayshift staff, and she was not familiar with any night shift staff. F3 stated her family reviewed the surveillance camera's video footage every day, and there had not been any instances where the staff did not check on her mother. She stated usually, her mother was checked on regularly throughout the night. F3 expressed concern that no one checked on her mother at all the night before last, and Resident R24 was not given her pain medications. F3 stated Resident R24 was admitted to Hospice to provide end of life care and manage her pain due to Parkinson's disease and severe spinal pain.

During an interview with F2 on 03/14/2025 at 3:35 PM, he stated the family placed a surveillance camera in Resident R24's room to monitor her. F2 stated the surveillance camera was designed to record video footage the moment it detected any movement in the room. Furthermore, F2 stated the camera would follow and maintain focus on any activity occurring throughout the room, including Resident R24's movements in bed. F2 stated

the surveillance camera operated 24 hours a day, seven days a week, to ensure comprehensive monitoring at all times. He stated staff was aware of the camera as there was a sign located outside of Resident R24's room, which announced video surveillance was in progress. F2 stated, after reviewing the video he discovered that no staff member had entered Resident R24's room from 03/11/2025 at approximately 6:03 PM to 03/12/2025 at 5:45 AM. He stated he was concerned that his mother was not observed, provided care, or administered her 9:00 PM pain medications.

The SSA Surveyor attempted a telephone interview with RN6 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. However, no return call was received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 During an interview with the Director of Nursing (DON) on 03/13/2025 at 11:30 AM, she stated F3 made a compliant to her, on 03/12/2025 in the morning, that her mother had not received care during the night. The Level of Harm - Minimal harm or DON stated F3 told her she had video surveillance showing Resident R24 was left alone all night. The DON stated she potential for actual harm notified the Administrator, and an investigation began. According to the DON, she reviewed Resident R24's MAR and noted that RN6 had documented she had administered Resident R24's 9:00 PM medications, which were given at Residents Affected - Few 9:21 PM. The medications included a scheduled pain medication and an external pain patch. The DON stated when she interviewed RN6, the nurse told her that she had provided the care and medication as documented in the resident's record. The DON stated, upon assessing resident Resident R24, she discovered Resident R24 was not wearing an external pain patch. She stated this was when she realized that RN6 had not provided care to Resident R24 during the evening shift. The DON stated it was her expectation that nursing staff rounded on residents regularly and provided ordered care. She stated nursing staff was required to administer prescribed medication as directed to ensure residents achieved their highest level of functioning, received adequate pain control, and maintained their overall 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 Resident R24 by the DON. She stated that she, the DON, and the Nurse Consultant met with Resident R24's family to address their concerns. The Interim Administrator requested to review

the video footage, and F3 showed her the complete recording using the monitoring application on her iPhone. She stated she (the Interim Administrator) and Social Services reviewed the video footage with the family present. The Interim Administrator stated the video revealed Resident R24 did not receive medicine or bedside care as documented. The Interim Administrator stated she initiated an investigation and suspended the staff members involved. She stated it was her expectation that clinical staff provided care as ordered to include administration of pain medications. She stated it was important to maintain adequate pain control to promote

the residents' well-being.

During an interview with the Medical Director on 03/13/2025 at 3:08 PM, he stated he was informed about a video from Resident R24's family, which revealed Resident R24 was not monitored by clinical staff throughout the night. He stated it appeared Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44001 potential for actual harm Based on observation, interview, record review, review of the Centers for Disease Control and Prevention Residents Affected - Few (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 33 sampled Residents (R) 8, Resident R18, and Resident R20.

1. Observation and interview on 03/11/2025 revealed State Trained Nurse Aide (STNA) 11 did not put on personal protective equipment (PPE) before providing care for Resident R20's who was under contact isolation precautions. Additionally, STNA11 failed to perform hand hygiene before entering or after exiting the room.

2. Observation and interview on 03/11/2025 revealed that a Hospice Certified Nursing Assistant (CNA) failed to remove her gloves after providing care for Resident R18, who was under enhanced barrier precautions, before exiting the room. The CNA removed her contaminated gloves in the hallway and placed them on top of the PPE container. The CNA failed to perform hand hygiene before opening the drawers to the PPE container.

3. Observation and interview on 03/12/2025 revealed Licensed Practical Nurse (LPN) 3 failed to implement infection control practices during Resident R24's medication administration preparation, including the use of gloves when touching medication. Additionally, LPN3 placed Resident R8's hydroxyzine oral tablet directly on top of the medication cart without a barrier.

The findings include:

Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], undated, revealed the facility maintained an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. All staff are responsible for adhering to IPCP policies, including the use of PPE and hand hygiene according to established procedures.

Review of the Centers' for Disease Control and Prevention (CDC) Guidelines, titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care is completed. Ensure proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious materials.

Review of the facility's policy titled Transmission-Based Precautions [TBP], undated, revealed staff will implement TBP precautions alongside standard precautions for residents known or suspected to be infected with certain agents to prevent transmission.

Review of the facility's policy titled Enhanced Barrier Precautions [EBP], undated, revealed staff will implement EBP precautions to include targeted gown and glove use during high contact care activities for residents known or suspected to be infected with multi drug-resistant organisms (MDRO).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the facility's policy titled Medication Administration, undated, revealed while preparing medication for administration, nursing staff should not touch the medication with bare hands. Level of Harm - Minimal harm or potential for actual harm 1. Review of an Admission Record, found in Resident R20's EMR, revealed the facility admitted Resident R20 on 05/02/2023 with diagnoses that included Parkinson's disease, spondylosis (degeneration of the vertebral column) and Residents Affected - Few urinary tract infections (UTI) related to Escherichia coli (E. coli, a bacterial infection).

Review of Resident R20's Quarterly Minimum Data Set (MDS), found in the electronic medical records (EMR), with an Assessment Reference Date (ARD) of 12/31/2024, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact.

Review of the CCP, dated 01/07/2025, revealed the facility care planned Resident R20 for a history of recurrent UTIs related to E coli. Goals included Resident R20's infection would be resolved without complications. Interventions included placing Resident R20 in contact precautions.

Review of the Physician's Order Summary Report, found in Resident R20's EMR, revealed the facility placed Resident R20 on contact isolation precautions on 02/28/2025 for an urinary tract infection caused by Escherichia coli (bacteria).

During an observation on the St. [NAME] Unit on 03/11/2025 at 11:45 AM, STNA11 was observed taking a lunch tray into Resident R20's room, a contact isolation room. STNA11 transferred Resident R20 from her bed to her recliner and set up her lunch tray. The STNA left the room and did not perform hand hygiene.

During an interview with STNA11 on 03/11/2025 at 12:05 PM, she stated that she was unaware that Resident R20 was under contact precautions and did not notice the CDC signage on the door. She stated that she forgot to perform hand hygiene. STNA11 stated that she had received education on infection control through her staffing agency prior to her assignment at the facility. She stated that the facility's policy required staff to wear a gown and gloves at all times while in a contact precaution room and to perform hand hygiene both

before and after providing care to protect both the resident and staff from the spread of infection.

2. Review of the Admission Record, found in Resident R18's EMR, revealed the facility admitted Resident R18 on 01/07/2025 with diagnoses that included end-stage renal disease (ESRD), anemia, and malnutrition.

Review of a Quarterly MDS found in Resident R18's EMR, with an ARD of 01/13/2025, revealed a BIMS score of 07 out of 15, which indicated the resident was severely cognitively impaired.

During an observation of the St. [NAME] Unit on 03/11/2025 at 12:46 PM, a Hospice CNA was observed to exit Resident R18's room, an EBP room, wearing gloves. Further observation revealed the CNA removed her contaminated gloves in the hallway and placed them on top of the PPE container. She did not perform hand hygiene before opening the drawers to the PPE container to pull additional PPE out of the drawers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview with the Hospice CNA on 03/11/2025 at 12:46 PM, she stated that she was not an employee of the facility. She stated she worked for Hospice and was visiting Resident R18. She stated she provided Level of Harm - Minimal harm or care to Resident R18 and was coming out of the room to get a gown. She stated she forgot to remove her gloves and potential for actual harm perform hand hygiene before exiting the room. She stated she had received infection control training as part of her CNA curriculum. The CNA stated it was important to follow infection control procedures to prevent the Residents Affected - Few spread of disease.

3. Review of the Admission Record, found in Resident R8's EMR, revealed the facility admitted Resident R8 on 08/01/2022 with diagnoses that included dementia, anxiety, and atherosclerotic heart disease.

Review of the Quarterly MDS found in Resident R8's EMR, with an ARD of 02/11/2025, revealed a BIMS score of 11 out of 15, which indicated the resident was moderately impaired.

Review of the CCP, dated 03/03/2025, revealed the facility care planned Resident R8 as at risk for behaviors associated with cognitive decline. Interventions initiated on 08/03/2022, included to give medications as ordered.

Review of Physician Orders, found in Resident R8's EMR, dated 02/25/2025, revealed the physician ordered hydroxyzine HCL, 25 milligram (mg) oral tablet, one tablet by mouth every six hours as needed for anxiety.

Observation on the St. [NAME] Unit on 03/12/2025 at 1:00 PM, revealed LPN3 touching Resident R8's hydroxyzine 25 mg capsule with ungloved hands. She took the capsule out of the medication pack and placed it directly on top of the medication cart without first placing the pill in a cup.

During an interview with LPN3 on 03/12/2025 at 1:00 PM, she stated that Resident R8's medications were to be administered in crushed form, and she was in the process of preparing the medications. She stated she should not have placed the pill on the medication cart as it could have been contaminated. LPN3 stated that following infection control procedures was important to prevent the spread of infection and cross-contamination. Further interview revealed that LPN3 was unaware of the requirement to wear gloves when handling medications. She stated she had received training on infection control and medication administration upon hiring; however, she had not been instructed to use gloves when touching medications with her bare hands.

During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 03/11/2025 at 1:50 PM, she stated that the facility adhered to the CDC's guidelines and followed the facility's infection prevention and control policies (IPCP). According to the IP/SDC, all staff members, including those from the agency, received education related to IPCP. She stated all staff were trained upon hire in the use of PPE and isolation precautions, including contact precautions and EBP. The IP/SDC stated the facility's vendors, including Hospice staff should follow the CDC guidelines for infection control. She stated if they were unsure,

they have been advised to consult with a staff member.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During continued interview, on 03/11/2025 at 1:50 PM, the IP/SDC stated she was unsure why some staff did not follow isolation precautions despite having been educated on the importance of observing the signs Level of Harm - Minimal harm or posted on doors. She stated each TBP/EBP room was equipped with a CDC sign and a yellow stop sign to potential for actual harm indicate that PPE was required. Additionally, each precaution room has an individual PPE cart located outside the door. She stated gowns and gloves must be worn whenever staff entered a contact precaution Residents Affected - Few room, or an EBP room if they were providing high-level care. She stated it was her expectation that all staff adhere to the facility's policies and procedures to help prevent the spread of infections. She stated it was important for the health and safety of the residents.

During an interview with the Director of Nursing (DON) on 03/13/2025 at 11:30 AM, she stated all staff received infection control training upon hire and periodically throughout the year. The DON stated staff was updated on current CDC guidelines when they changed. She stated it was her expectation that all staff maintained IPCP guidelines at all times to decrease the potential spread of infection.

During an interview with the Interim Administrator on 03/15/2025 at 11:46 AM, she stated it was her expectation that staff followed the facility's infection control policies to prevent the spread of infection to residents and staff.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 185208

F-F689, and Substandard Quality of Care (SQC) at 42 CFR 483.25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 34 185208 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 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 Level of Harm - Immediate exit. Remaining non-compliance continues at a Scope and Severity of a G while the facility develops and jeopardy to resident health or implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure safety compliance with systemic changes.

Residents Affected - Few Refer to