Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carmel Manor during CMS and state inspections, most recent first.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, and neglect by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and a lack of clear protocols for reporting and responding to incidents, increasing the risk that such events could go undetected or unaddressed.
A deficiency was cited when a resident's care plan did not address all assessed needs and failed to include measurable timetables or specific actions, resulting in incomplete planning and documentation.
The facility did not manage or allocate its resources in an effective and efficient manner, as required, resulting in a deficiency identified during the survey.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
The facility did not establish or maintain an infection prevention and control program, resulting in a deficiency related to infection control practices.
The facility did not maintain documentation showing that several staff members, including an RN and two LPNs, were offered the COVID-19 vaccine or received education about its benefits, risks, and side effects. Employee files lacked evidence of vaccine status or declination, and interviews confirmed that some staff had not been educated or asked about their vaccination status. The facility's leadership acknowledged the absence of required documentation and education for staff regarding COVID-19 immunization.
Two residents did not receive care as outlined in their person-centered care plans: one resident with dementia and a history of wandering was able to leave and re-enter the facility without staff knowledge or a functioning wanderguard alarm, while another hospice resident did not receive pain medication or care for approximately 12 hours overnight, as confirmed by surveillance footage. Staff failed to consistently implement and document required interventions, resulting in significant lapses in resident safety and comfort.
A facility failed to ensure adequate supervision and properly functioning assistance devices for three residents at risk for wandering, elopement, and falls. One resident repeatedly left the building without a required wanderguard, with staff failing to consistently check or document the device's presence and function, and the alarm system was found to be malfunctioning. Another resident was injured during a transfer performed without a gait belt by a staff member on orientation, with no investigation or care plan update. A third resident suffered a fall with injuries, but no root cause analysis or care plan revision was documented.
Two residents experienced falls and injuries, but the facility did not update their Comprehensive Care Plans (CCPs) with new interventions as required. One resident was not care planned for gait belt use after a fall with injury, and another had multiple falls, including one with a head injury, without documented CCP revisions or new fall prevention strategies by the interdisciplinary team.
A resident's ring went missing after being removed for cleaning by an STNA, and the incident was not reported to the SSA or local law enforcement within the required 24-hour period. Despite facility policy mandating immediate reporting, there was a delay in escalating the incident, with law enforcement only notified several days later. The resident, who had moderate cognitive impairment, was unaware of the loss, but family members expressed concern about the reporting delay.
A resident on hospice care for end-of-life pain management was left unattended in her room for over 11 hours overnight, during which time she did not receive required monitoring, assessments, or physician-ordered pain medication. Facility policies and care plans required regular rounding and medication administration, but surveillance video and staff interviews confirmed that these standards were not met.
A resident with advanced neurological and spinal conditions, under hospice care, was not administered scheduled pain medications or assessed for pain during an entire night shift. Video surveillance confirmed no staff entered the room, despite documentation indicating otherwise. The DON and Interim Administrator verified that required care was not provided, and the Medical Director acknowledged the missed medications.
Multiple staff failed to follow infection control protocols, including not wearing PPE or performing hand hygiene when required, and improper handling of medications. These lapses involved a resident on contact isolation for a bacterial infection, a resident under enhanced barrier precautions, and improper medication preparation by an LPN, all contrary to facility policy and CDC guidelines.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and responding to incidents of abuse, neglect, or theft. The absence of these measures contributed to an environment where such incidents could occur without prompt detection or intervention.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's assessed needs, nor did it include clear, measurable goals or interventions.
Ineffective and Inefficient Use of Facility Resources
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified during the survey process, as the facility did not demonstrate appropriate management or allocation of its available resources. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are there any direct observations or events involving residents or staff described.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a program designed to minimize the transmission of infectious diseases within the facility. No specific details about individual residents, staff, or particular incidents leading to the deficiency are provided in the report.
Failure to Document COVID-19 Vaccine Education and Status for Staff
Penalty
Summary
The facility failed to maintain proper documentation regarding COVID-19 vaccination screening, education, offering, and current vaccination status for three out of four sampled staff members, including a registered nurse and two licensed practical nurses. Review of employee files revealed no evidence that these staff members were offered the COVID-19 vaccine or provided with education about its benefits, risks, and potential side effects. Additionally, there was no documentation of their vaccination status or any declination of the vaccine. Interviews with staff confirmed that some had not been educated about or asked regarding their COVID-19 vaccination status, nor had they signed any related forms or provided vaccination cards. The Interim Director of Nurses/Infection Preventionist acknowledged that the facility had not provided or documented COVID-19 vaccine education for all employees and did not have the required documentation for staff immunization status. The Interim Administrator also confirmed the lack of appropriate documentation reflecting that required COVID-19 vaccine education was provided to employees. The facility's policy and CMS guidance require education, offering, and documentation of COVID-19 vaccination for staff, but these steps were not followed or recorded for the sampled staff members.
Failure to Implement Comprehensive Care Plans for Resident Safety and Pain Management
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in significant lapses in care. One resident with severe vascular dementia and a known history of wandering was care planned to wear a wanderguard device to prevent elopement. Despite this, the resident was able to leave the locked memory care unit without staff knowledge and re-entered the facility without triggering any alarms. Staff interviews revealed that while the placement of the wanderguard was checked, there was no consistent or documented process to verify the device's functionality, and the intervention to test the wanderguard was not present on the treatment administration record. The resident was not wearing the device upon return, and staff were unaware of his absence until notified by the receptionist. Another resident, who was on hospice care for Parkinson's disease and required substantial assistance with activities of daily living, was care planned for regular pain medication administration and monitoring. However, surveillance footage provided by the family showed that no staff entered the resident's room for approximately 12 hours overnight, during which time the resident did not receive pain medication or care as outlined in the care plan. Staff interviews confirmed that while some rounds were claimed, these did not always involve entering the room or providing direct care, and the medication administration documented in the record was not corroborated by the video evidence. The facility's own policy required comprehensive care plans with measurable objectives and interventions tailored to each resident's needs, including regular monitoring and documentation. In both cases, the care plans were not fully implemented or followed, resulting in residents not receiving essential safety measures or pain management as required. These failures were identified through interviews, record reviews, and direct observation, and were determined to have placed residents at risk for serious harm.
Removal Plan
- The function of the residents' wanderguards was to be checked.
- Placement of the residents' wanderguards was to be checked and charted on the TAR and in the Progress Notes.
- If a resident had a wanderguard, the wanderguard should be marked on the resident's care plan and Kardex in order to alert all staff the resident had a wanderguard.
- There would be an intervention to check placement and functionality on R1's care plan and that would flow to the STNA Kardex.
Failure to Prevent Accidents Due to Inadequate Supervision and Device Management
Penalty
Summary
The facility failed to maintain an effective system to ensure resident safety and prevent accidents, specifically regarding supervision and the use of assistance devices for residents at risk of wandering, elopement, and falls. One resident with a history of wandering and diagnosed with severe vascular dementia was ordered to wear a wanderguard bracelet, which was to be checked every shift. Despite these orders, the resident was found outside the facility without the wanderguard on two separate occasions. Staff interviews revealed that checks for the presence and functionality of the wanderguard were inconsistently performed and not documented as required. Additionally, the facility's electronic alarm system was found to be malfunctioning, and logs of system checks were not provided when requested. The facility's policy required regular checks and documentation of both the devices and the alarm system, but these were not consistently followed. Another resident, who required substantial assistance for transfers due to impaired mobility and moderate cognitive impairment, sustained multiple injuries including a rib fracture after being transferred without the use of a gait belt, contrary to facility policy. The staff member responsible was on orientation and should not have been performing resident care independently. There was no documented evidence of a root cause analysis or investigation following the fall, and the care plan was not updated to reflect the need for a gait belt during transfers. A third resident with Alzheimer's disease and a history of falls experienced an unwitnessed fall resulting in a hematoma and lacerations requiring sutures. There was no documented evidence of a root cause analysis or investigation, and the resident's care plan was not updated to address fall prevention after the incident. The facility's policies required post-fall assessments, care plan updates, and interdisciplinary team reviews, but these actions were not documented. These failures in supervision, device functionality, and post-incident follow-up contributed to the deficiencies cited by surveyors.
Failure to Revise Care Plans After Falls and Injuries
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team for two residents following significant changes in their condition and incidents. For one resident with myasthenia gravis, a history of transient cerebral ischemic attack, and type 2 diabetes, the care plan was not updated to include the use of a gait belt during transfers, despite a fall that resulted in multiple injuries, including a rib fracture. The facility's policy required the use of a gait belt for residents unable to transfer independently, but this intervention was not added to the care plan after the incident. Another resident, diagnosed with Alzheimer's disease, muscle weakness, and reduced mobility, experienced six falls over a period of time, including one that resulted in a head injury requiring sutures. Despite these repeated falls and documented injuries, there was no evidence that the CCP was revised with new interventions to prevent recurrence. The facility's fall prevention policy required reassessment and the addition of interventions after each fall, but this was not documented in the care plan or verified by the interdisciplinary team. Interviews with facility staff, including the MDS Nurse, LPN, DON, and Interim Administrator, confirmed that care plans should have been updated to reflect new interventions after falls or changes in resident condition. Documentation review revealed that the required interdisciplinary review and revision of care plans did not occur as per facility policy, and interventions such as the use of a gait belt or specific fall prevention strategies were not consistently added to the care plans after incidents.
Failure to Timely Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that an alleged misappropriation of a resident's property was reported to the State Survey Agency (SSA) and local law enforcement within the required 24-hour timeframe. According to the facility's policy, any suspicion or allegation of misappropriation must be reported immediately to a supervisor or the Administrator, and then to the appropriate authorities within 24 hours. In this case, a State Tested Nurse Assistant (STNA) reported that a resident's ring went missing after it was removed for cleaning and left on the sink. The STNA and another aide searched for the ring but could not locate it, and the incident was documented in a written statement. Despite the policy requirements, the initial notification to local law enforcement did not occur until several days after the incident. The written statements and interviews revealed that the STNA informed a Licensed Practical Nurse (LPN) about the missing ring, who then instructed the STNA to write a statement and submit it to her supervisor. However, there was no immediate follow-up to ensure the report was escalated as required. The Social Services Director and Registered Nurse (RN) became aware of the missing ring over a week later, at which point law enforcement was finally notified. The delay in reporting was confirmed through interviews with staff and review of facility documentation. The resident involved had a history of Alzheimer's disease, unspecified dementia, and anxiety, and was assessed to have moderate cognitive impairment. Interviews with the resident indicated she felt safe and was unaware of any missing belongings. However, family members expressed concern about the delay in notifying law enforcement, believing it may have impacted the chances of recovering the ring, which held significant sentimental value. The deficiency centers on the facility's failure to follow its own policy and regulatory requirements for timely reporting of suspected misappropriation.
Failure to Provide Required Monitoring and Pain Management
Penalty
Summary
A deficiency occurred when a resident, who was admitted with Parkinson's disease, spinal stenosis, and was on hospice care for end-of-life pain management, was left unattended in her room for approximately 11 hours and 38 minutes overnight. Surveillance video provided by the resident's family showed that after being assisted into bed by a staff member at 6:03 PM, no facility personnel entered the resident's room until 5:41 AM the following morning. During this period, the resident did not receive any monitoring, assessments, or physician-ordered care, including the administration of pain medication. Facility policies and job descriptions required staff to routinely round on residents, administer medications as ordered, and provide care in accordance with professional standards. The resident's care plan specifically included goals for pain management, timely administration of pain medication, and monitoring for effectiveness. Despite these requirements, the resident's medication administration record indicated that her 9:00 PM pain medication was documented as given, but the video evidence contradicted this, showing no staff entry into the room during the relevant time frame. Interviews with staff revealed inconsistencies in their accounts of rounding and care provided. One nursing assistant stated he checked on the resident hourly by opening the door but did not always enter the room or turn on the lights, while another stated she rounded but did not provide care. The Director of Nursing, Interim Administrator, and Medical Director all confirmed that the resident was not monitored or provided care as required during the night, and the Medical Director noted that the resident did not receive her evening medications.
Failure to Provide Scheduled Pain Management and Monitoring
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, spinal stenosis, and severe chronic pain, who was also on hospice care, did not receive scheduled pain management and was not assessed for pain over the course of an entire night. Surveillance video provided by the resident's family confirmed that no staff entered the resident's room from the evening until the following morning, despite physician orders for regular pain medication administration and pain assessments every shift. The resident's Medication Administration Record (MAR) indicated that a registered nurse documented the administration of scheduled pain medications and a pain patch, as well as a pain assessment, but video evidence and subsequent assessment by the Director of Nursing (DON) revealed that these interventions were not actually provided. The facility's policies required that pain management be provided in accordance with professional standards and the resident's comprehensive care plan, which included regular pain assessments and timely administration of prescribed medications. The resident's care plan specifically outlined the need for scheduled and as-needed pain medications, monitoring for pain symptoms, and documentation of the effectiveness of interventions. Despite these requirements, the resident was left unattended, did not receive her scheduled 9:00 PM pain medications, and was not monitored for pain or other care needs throughout the night. Interviews with the family, DON, Interim Administrator, and Medical Director confirmed the lapse in care, with the DON and Interim Administrator acknowledging that the nurse had documented care that was not actually provided. The family, who monitored the resident via a surveillance camera, reported that this was the first instance where the resident was not checked on during the night. The Medical Director confirmed that the resident did not receive her evening medications and emphasized that such occurrences should not happen.
Failure to Adhere to Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established infection control practices. In one instance, a State Trained Nurse Aide (STNA) entered the room of a resident who was under contact isolation precautions for a urinary tract infection caused by Escherichia coli. The STNA did not don personal protective equipment (PPE) or perform hand hygiene before or after providing care, despite facility policy and CDC guidelines requiring these actions. The STNA later stated she was unaware of the resident's isolation status and had forgotten to perform hand hygiene. In another case, a Hospice Certified Nursing Assistant (CNA) exited the room of a resident under enhanced barrier precautions while still wearing contaminated gloves. The CNA removed the gloves in the hallway and placed them on top of the PPE container, then failed to perform hand hygiene before accessing additional PPE. The CNA admitted to forgetting to remove gloves and perform hand hygiene, despite having received infection control training as part of her CNA curriculum. Additionally, a Licensed Practical Nurse (LPN) was observed preparing medication for a resident by touching an oral tablet with ungloved hands and placing it directly on the medication cart without a barrier. The LPN stated she was unaware of the requirement to wear gloves when handling medications and acknowledged that placing the pill on the cart could result in contamination. These actions were inconsistent with the facility's policies and CDC guidelines, which require proper hand hygiene, use of PPE, and safe medication handling to prevent the transmission of communicable diseases and infections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Thomas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highlandspring Of Ft Thomas | 1.5 mi | — | 3 | 0 |
| St Elizabeth Ft Thomas Snf | 1.7 mi | — | 0 | 0 |
| Residence At Salem Woods | 2.8 mi | — | 0 | 0 |
| The Pavilion At Kenton | 3.2 mi | — | 7 | 0 |
| Rosedale Green | 3.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.