Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carmel Home during CMS and state inspections, most recent first.
Failure to complete monthly pharmacist MRRs for multiple residents. The facility’s policy required a licensed pharmacist to review each resident’s med regimen at least monthly, document findings in the chart, and send written reports to the attending MD. Record review showed four residents with Alzheimer’s disease and other diagnoses had no documented monthly MRRs for several months, despite BIMS scores indicating severely impaired cognition. The pharmacist said he reviewed some charts and spoke with the DON by phone, but did not provide written documentation or communicate with the physician, and the DON and Administrator acknowledged the reviews were not consistently completed.
Failure to Submit PBJ Staffing Data: The facility failed to electronically submit complete and accurate direct care staffing information to CMS for a PBJ quarter. The BOM said her computer had been hacked and replaced, and she could not log in from the DON's computer even with verification codes. The DON said she knew nothing about the PBJ report, and the Administrator stated the facility had computer issues and the BOM was unable to access her account to submit the data.
The facility failed to ensure several residents’ drug regimens were free from unnecessary medications. Four residents with severe cognitive impairment had psychotropic medications ordered without clear documented diagnoses or supporting behavior documentation, including antipsychotics ordered for dementia with agitation and antidepressants for depression. The consulting pharmacist also did not complete consistent monthly MRRs, and staff interviews showed confusion about who was performing and documenting the reviews.
An unsecured gray tote containing 36 medication cards with pills was found on the floor outside the locked med storage area, while other boxes nearby contained only empty cards. RN stated she did not know why the meds were in the tote, and the DON acknowledged the meds should not have been left unsecured; the Administrator said the tote should have been returned to the pharmacy immediately.
The facility failed to provide RN coverage for at least eight consecutive hours a day, seven days a week, from July through September 2023. The Administrator, who is also an RN, assumed her presence onsite sufficed, but her hours did not count towards the required RN coverage. The facility faced challenges in hiring RNs, and the DON was always on call to cover call-ins.
The facility failed to store, label, and date food in accordance with professional standards. Observations revealed unlabeled and undated containers of caramel and cheese sauce in walk-in cooler #1, and forty-one Styrofoam cups of various liquids in walk-in cooler #2. The Certified Dietary Manager confirmed these items should have been labeled and dated.
The facility failed to post daily staffing data for two out of three days of the survey. Observations revealed outdated staffing information, and interviews with the DON and Administrator confirmed the lapse in updating the white board, which was the night shift staff's responsibility.
Failure to Complete Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed monthly medication regimen reviews (MRRs) for 4 of 5 sampled residents. The facility policy required a licensed pharmacist to review each resident’s medication regimen at least once a month, document findings and recommendations in the medical record, and provide a written report to the attending physician within 24 hours. The pharmacy service agreement also described routine medication regimen reviews as part of the pharmacist’s services. Record review showed no documented evidence that monthly MRRs were completed for residents with significant cognitive impairment and multiple diagnoses. One resident admitted with major depressive disorder, Alzheimer’s disease, and type 2 diabetes mellitus had no documented monthly MRRs for 12/2025, 01/2026, 02/2026, and 04/2026. Another resident admitted with anxiety disorder, Alzheimer’s disease, and chronic kidney disease had no documented monthly MRRs for 12/2025, 01/2026, 03/2026, and 04/2026. A third resident admitted with generalized anxiety disorder, Alzheimer’s disease, and other depressive disorders had no documented monthly MRRs for 12/2025, 01/2026, 02/2026, and 04/2026. A fourth resident admitted with anxiety disorder, Alzheimer’s disease, and other seizures also had no documented monthly MRRs for 12/2025, 01/2026, 02/2026, and 04/2026. The residents’ MDS assessments showed BIMS scores of 3 to 6, indicating severely impaired cognition. During interview, the pharmacist stated he had reviewed some charts and spoken with the DON by telephone, but had not communicated with the physician and had not provided written documentation of his chart reviews. The DON stated she had not seen written reports and said the pharmacist had not consistently completed reviews monthly. The Administrator stated the MRRs had “fell through the cracks” during a pharmacy transition.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data in the required uniform format. Review of the PBJ Staffing Report for FY Quarter 1 2026 showed that no data was submitted for that quarter. During interview, the BOM stated she was unable to submit the required information because her computer had been hacked and needed to be replaced, and she reported that she could not log in to the system even when trying from the DON's computer using verification codes for her account. The BOM provided the surveyor with quarter 2 documents showing correct information had been submitted, along with approximately 500 pages of computer code that could not be read. The DON stated she knew nothing about the facility's PBJ report and said the Administrator and business office handled it. The Administrator stated the facility had computer issues and that someone appeared to be trying to hack the system, which led to the BOM's computer being shut down and the BOM being unable to access her account from the DON's computer to submit the PBJ information.
Unnecessary Psychotropic Medications and Incomplete Medication Reviews
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary medications for 4 of 5 sampled residents reviewed for drug regimen concerns. The facility policy required all medications, including psychotropics, to be clinically indicated, appropriately dosed, monitored for effectiveness and adverse consequences, and used according to current standards of practice. Review of records showed that several residents were receiving psychotropic medications without a documented diagnosis or other clear indication matching the ordered use, and the facility’s monthly medication regimen review process was not being completed consistently by the consulting pharmacist. For one resident with severe cognitive impairment and a BIMS score of 3, the record showed orders for Rexulti for dementia with behaviors and citalopram for depression, but the diagnosis list did not include a diagnosis supporting those uses. Behavior monitoring documented wandering on multiple days, but there was no documentation of the behaviors described in the order. For another resident with severe cognitive impairment and a BIMS score of 5, the record showed clomipramine, sertraline, and Seroquel ordered for depression and dementia with agitation, but no indication for Seroquel was documented. For a third resident with severe cognitive impairment and a BIMS score of 6, Seroquel was ordered for dementia with agitation without documented evidence of that diagnosis, and behavior monitoring documented socially inappropriate/disruptive behaviors and verbal abuse. For a fourth resident with severe cognitive impairment and a BIMS score of 6, the record showed fluoxetine, mirtazapine, and Seroquel ordered for depression and dementia with agitation, but the chart did not show diagnoses of depression or dementia with agitation, and no behaviors were documented for the month reviewed. The record review also showed that the licensed pharmacist did not complete monthly medication regimen reviews as required for these residents, with gaps across multiple months and only limited reviews documented. During interview, the pharmacist stated he had assumed consulting services in December 2025, had communicated with the DON by telephone, had not provided written documentation of his reviews, and was not aware that written reports were required. The physician stated he had been covering for the Medical Director and said monthly medication reviews were done, while the DON stated she was not aware the pharmacist was not completing the MRRs and believed he had been doing them. The Administrator stated the physician did monthly medication reviews and that the facility did not usually do dose reductions.
Unsecured Medications Left Outside Locked Storage
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible when an open gray plastic tote containing 36 medication cards with pills was found unsecured on the floor outside the locked medication storage area. Review of the facility policy titled, Storage of Medications, stated medications were to be stored securely in a designated, secured area accessible only to authorized personnel. Observation of the medication storage area revealed four cardboard boxes and one gray plastic tote sitting on the floor outside the locked area; the cardboard boxes contained empty medication cards only, while the gray tote contained medication cards with pills remaining in them. During interview, RN 1 stated the containers were supposed to contain empty medication cards for pharmacist review, but she was unsure why the medications were in the gray tote and unsecured. The DON acknowledged the medication cards should not have been sitting out unsecured and stated they should have been stored in the locked storage area. The DON later stated the tote had been moved to a locked room after the concern was brought to her attention and said wanderers on the unit could have accessed the medications. The Administrator stated the gray tote of medications in the hallway should have been returned to the pharmacy immediately.
Failure to Provide Continuous RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, from July 1, 2023, through September 30, 2023. Specifically, the facility's daily staffing sheets revealed gaps in RN coverage on multiple days in July and September 2023. The facility's policy mandates sufficient qualified nursing staff to meet residents' needs, but this requirement was not met on several occasions. The Business Office Manager (BOM) and the Director of Nursing (DON) were unaware that the Administrator's hours, despite being an RN, did not count towards the required RN coverage. The DON acknowledged the lack of a dedicated RN for weekends and believed resident safety was maintained because the Administrator, who is also an RN, lived onsite. Interviews with the BOM, DON, and Administrator revealed a misunderstanding regarding the counting of the Administrator's hours as RN coverage. The Administrator admitted awareness of the RN coverage gaps but assumed her presence as an RN living onsite sufficed. The facility faced challenges in hiring RNs, and the DON was always on call to cover any call-ins. However, this did not fulfill the regulatory requirement for continuous RN coverage, leading to the identified deficiency.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to store, label, and date food in accordance with professional standards for food service safety. During an observation of the kitchen, it was found that walk-in cooler #1 contained a plastic container partially full of a brown substance and another container full of a yellow/orange substance, both of which were not labeled or dated. Additionally, walk-in cooler #2 contained a tray with forty-one ten-ounce Styrofoam cups of various liquids that were also not dated. The Certified Dietary Manager confirmed that the brown substance was caramel sauce and the yellow/orange substance was cheese sauce left over from a facility party. She also stated that the tray of various liquids was from the supper meal the previous night and acknowledged that these items should have been labeled and dated prior to storage.
Failure to Post Daily Staffing Data
Penalty
Summary
The facility failed to post daily staffing data for two out of the three days of the survey. According to the facility's policy, the daily posting should include the facility name, current date, resident census, and the actual number of nursing staff on duty each shift, including RNs, LPNs, Medication Aids, and Nursing Assistants. Observations on 02/13/2024 and 02/14/2024 revealed that the staffing information posted for the 300 Hall was outdated, showing the date 02/08/2024. Interviews with the DON and the Administrator confirmed that the white board had not been updated since 02/08/2024, and it was the night shift staff's responsibility to update it. The Administrator acknowledged the failure to maintain accurate daily staff postings.
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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 Owensboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellington Parc Of Owensboro | 0.4 mi | ★★★★★ | 7 | 0 |
| Chautauqua Health And Rehabilitation | 1 mi | ★★★★★ | 8 | 0 |
| Signature Healthcare At Hillcrest | 1 mi | ★★★★★ | 1 | 0 |
| Hermitage Care And Rehabilitation Center | 1.9 mi | ★★★★★ | 3 | 0 |
| The Transitional Care Center Of Owensboro | 2.1 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 October 2026) and official state health department websites.