Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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.
Insufficient dietary staffing led to nursing staff picking up and delivering meal carts, serving trays on the units, and residents in the same room receiving meals at different times. A resident with diabetes and insulin use reported that his roommate routinely finished breakfast before his tray arrived, and observation confirmed his tray was delivered well after his roommate had already started eating. The Dietary Manager stated the department was short-staffed, and a CNA reported that aides were responsible for cart transport, tray delivery, feeding assistance, tray collection, and cart return during mealtimes.
Meals were repeatedly delivered late, including breakfast, lunch, and supper, and residents were left waiting while trays were sorted and distributed. A resident missed breakfast for an appointment, and family members and staff reported that delayed meals disrupted medication timing, bedtime routines, ADLs, and resident mood. Staff also described tray-order problems, dietary staffing shortages, and a difficult ticketing system that contributed to the delays.
Unsafe Food Storage and Uncovered Kitchen Equipment: Surveyors found uncovered kitchen utensils and equipment in the kitchen production area, including mixing bowls, a Robo Coupe blade, and a stand mixer. They also found multiple resident food items in unit kitchenette refrigerators that were not labeled with the resident’s name, date received, or food identity, with no visible temp log in one unit and a non-working thermometer in another. The Dietary Manager, DON, and Administrator all stated that resident food should be labeled and that equipment should be covered.
Infection prevention and control practices were not consistently followed across the facility. Staff were observed failing to use proper PPE and hand hygiene, not cleaning shared equipment after use, mishandling linen, and not following contact precautions or EBP for residents with MRSA, C. diff, wounds, catheters, oxygen, and enteral feeding tubes. The facility also lacked a facility-specific water management plan and flow diagram.
Food and drink were not kept at safe serving temperatures during supper service. Facility policy required foods not remain unrefrigerated for more than one hour and identified the danger zone as 41 degrees F to 135 degrees F, yet the meal temperature log showed cold items below 40 degrees F and soup at 181 degrees F. On the unit, five trays remained on the cart for residents who were in a meeting, and later observation found cold items such as applesauce, water, lemonade, fruit, and salads at 69 to 75 degrees F, with broccoli cheddar soup at 101 degrees F. The ADM stated the plates were not cold because staff forgot to take them out of the warmer prior to service.
A resident with ESRD, DM, and depression had a care plan requiring a mechanical lift with two staff for transfers, but staff left the resident suspended in a Hoyer lift while one aide went to get help. The resident reported being left in the air, a CNA saw the resident in the lift, and the DON stated the investigation determined two CNAs walked out of the room while the resident was still in the lift.
The facility failed to maintain resident dignity in catheter care, dining, and staff communication. A resident with a suprapubic catheter was observed multiple times without a dignity cover, another resident was served her meal well after her tablemates and stated this happened regularly, and a CNA loudly referred to a resident as a feeder in front of others. Staff and leadership acknowledged these actions were dignity concerns, and facility policies required catheter privacy and dignity during mealtimes.
The facility failed to ensure that two residents were informed and provided written information about the right to formulate an advance directive. Both residents had DNR documents in the EMR and care plans referencing advance directives, but there was no documentation that advance directive information had been provided. One resident was non-verbal with serious respiratory and neurologic diagnoses, and the other was cognitively intact with diagnoses including psychotic disturbance, bipolar disorder, and stroke-related impairment.
Failure to resolve and document missing-item grievances for two cognitively intact residents was identified after Resident Council minutes and record review showed repeated reports of missing clothing and shoes with no resolution provided. One resident had diagnoses including MS and scoliosis, and the other had diagnoses including convulsions, hemiplegia/hemiparesis after CVA, and anxiety. Facility policy required grievance investigation, tracking, and written decisions, but records showed unresolved missing-property reports and staff interviews confirmed the grievances had not been fully addressed.
Failure to provide written transfer, discharge, and bed-hold notices: The facility did not give 3 residents and their representatives the required written notices for emergency transfers/discharges, including the reason for the move, transfer date and location, appeal rights, and LTC Ombudsman contact information. The EMR had no transfer/discharge or bed-hold notices for any of the residents, and family members reported they were only called and told verbally about the transfers.
A resident with ESRD receiving hemodialysis had inconsistent dialysis communication between the facility and the dialysis clinic. The resident’s care plan required written communication for every treatment, but staff reported they did not consistently send or receive the dialysis form, and one RN said she had never heard of it or communicated with the clinic. The dialysis clinic also reported the form was only sometimes sent, while the DON and Administrator stated the form was expected for continuity of care but had not been consistently completed.
Medication Storage and Labeling Deficiencies: Surveyors observed an unlabeled strip of Dulcolax stored with one resident's meds, an albuterol inhaler stored with oral meds, and four insulin pens stored loosely without full labels or separate packaging on medication carts. Staff, including an LPN, RN, unit manager, DON, and the Administrator, stated meds should be clearly labeled and separated by route, with insulin pens kept in individual bags for infection control and cross-contamination prevention.
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.
Insufficient Dietary Staffing and Delayed Meal Delivery
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services. During breakfast service, nursing staff rather than dietary staff took tray carts to the units and served residents. Observation showed the Dietary Manager working the tray line with a dietary aide, while other kitchen staff assisted, and then dietary staff called the units to notify them that tray carts were ready for pickup. The last breakfast tray cart was sent to a unit at 8:41 AM, within the scheduled breakfast window of 8:00 AM to 9:00 AM. The staffing issue affected meal delivery on the units, where residents in the same room were served at different times. One resident with diabetes and long-term insulin use, who had a BIMS score of 15, stated he always ate breakfast in his room and that his roommate routinely finished eating before his tray arrived. Observation showed the roommate had already eaten about 50 percent of the meal at 8:30 AM, while the resident did not receive his breakfast tray until 8:57 AM. The resident stated he repeatedly asked staff where his breakfast was and why it was always late, but no explanation or resolution had been provided. The Dietary Manager stated the department had only nine current employees and needed seven staff each day to perform required functions, and that the department was down three positions. A CNA stated that nursing aides were responsible for picking up meal carts, delivering trays, providing feeding assistance, collecting trays, and returning carts to the kitchen, and that this routinely left only two aides on the unit for 39 residents during mealtimes. The former Dietary Manager stated the former Administrator had cut dietary staffing and assigned nursing staff to pick up and deliver meal carts, and the Administrator stated there was concern that residents were not receiving trays at the same time because of current meal ticketing issues in the kitchen.
Late Meal Delivery Disrupted Resident Routines
Penalty
Summary
Meals and snacks were not served at times consistent with residents’ needs, preferences, and requests, and the facility did not provide meals at regular times comparable to normal mealtimes in the community or to which residents were accustomed. Observations on 09/16/2025, 09/17/2025, 09/18/2025, and 09/19/2025 showed breakfast, lunch, and supper being delivered late, including one supper meal that was still not delivered until 5:58 PM after residents had been waiting at the table since 5:15 PM. Additional time was then needed to sort out tray delivery to diners at the table, further delaying service. Residents and family members described how the late meals disrupted routines and affected daily care. One resident asked why a cold dinner was an hour late, and another resident left the dining room without breakfast because the meal had not been served before she had to leave for an appointment. A family member of a resident who required feeding assistance stated late lunch and supper delayed medications and bedtime routines, and another family member stated late supper trays delayed transfer to bed and preparation for sleep. A resident who depended completely on staff for eating and other ADLs stated late breakfast could delay oral care, dressing, transfer to a wheelchair, and attendance at morning Mass. Staff interviews confirmed that meal timing problems were ongoing and affected residents’ moods and routines. A CNA stated breakfast was very late and residents became frustrated when they had to wait hungry, and that trays were not in any particular order, which added to delivery delays. An LPN stated late meals were a real problem for residents with appointments and could affect blood sugar and anxiety, especially for residents with dementia. The Dietary Manager stated breakfast should be served from 8:00 AM to 9:00 AM but the department was short-staffed, and the Administrator stated the meal ticketing system was difficult to follow and there had never been an organized system for arranging trays.
Unsafe Food Storage and Uncovered Kitchen Equipment
Penalty
Summary
Food was not stored and prepared in a safe manner in the facility kitchen and unit kitchenette refrigerators. On 09/16/2025, surveyors observed uncovered kitchen utensils and equipment in the kitchen production area, including nested mixing bowls turned upside down and not covered, an uncovered Robo Coupe blade with container, and an uncovered stand mixer with the mixing bowl in place. The facility’s policy required food items brought in for residents to be stored properly, sealed to prevent cross contamination, and labeled with the resident’s name and the date received, with refrigerator temperatures monitored daily. Surveyors also observed multiple resident food items in the unit kitchenette refrigerators that were not labeled with the resident’s name, date received, or identity of the food product. In one refrigerator, items included orange juice, broth or soup, yogurt, frozen food boxes containing meatloaf and stuffed peppers, and frozen deer meat, with no labels and no visible temperature log. In another refrigerator, items included tea, lemonade, cranberry juice, ice cream cake, frozen ice cream bars, fruit bars, taco salad, lemon meringue pie past its sell-by date, and pita chips, again with no labels and no visible temperature log; the thermometer in this refrigerator was not working. The Dietary Manager stated the equipment needed to be covered and that the kitchenette refrigerators were not for resident food storage, while the DON and Administrator stated resident food should be labeled with name and date.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as evidenced by multiple observations of staff not following hand hygiene, PPE, transmission-based precautions, shared equipment cleaning, linen handling, and water management requirements. Review of facility policies and CDC guidance showed expectations for hand hygiene before and after resident care, proper PPE use based on exposure risk, cleaning and disinfection of shared equipment, proper handling of linen, and a water management program with a facility-specific plan and flow diagram. The facility also had policies for contact precautions, enhanced barrier precautions (EBP), medication administration hand hygiene, and oxygen equipment changes. Several residents were observed with infection control practices not followed. R49 had oxygen tubing and humidification dated 09/07/2025 despite an order to change and label oxygen tubing and masks every Sunday. R15’s catheter collection bag was observed lying on the floor without a barrier underneath, and CNA13 provided care to R15 without wearing PPE even though the resident was on EBP. R58, who had EBP for a gastrostomy tube and a BIMS score of 11, was provided direct care by CNA2 without gloves or a gown; contaminated linen was placed on the floor, hand hygiene was not performed after handling soiled items, and a contaminated Hoyer lift was placed in clean storage without being cleaned and disinfected. R3, who had EBP for a pressure wound and a BIMS score of 12, had a Hoyer lift removed from the room and placed in the hallway without cleaning or disinfection. Additional observations showed contact precautions were not followed for residents with infectious conditions. LPN2 entered R68’s contact isolation room for MRSA in urine without gloves or a gown and did not perform hand hygiene when exiting and reentering the room. CNA7 entered R55’s room, which was on contact precautions for C. diff, without gloves or a gown, touched the bed and overbed table, and used alcohol-based hand rub instead of soap and water before leaving the room. During medication administration, LPN1 exited one resident’s room and began preparing medications for another resident without sanitizing her hands between residents. Linen handling was also observed to be inconsistent with infection control expectations, as CNA1 carried unbagged linen against her person to the dirty utility room and then went directly to the clean linen closet while still holding linen against her body. The facility also lacked documentation of a facility-specific water management plan and did not have a process flow diagram for the building’s water system; the Maintenance Director stated the binder contained CDC toolkit material rather than a facility-specific WMP, and the Administrator stated there was no written WMP or water management policy in place.
Food Served at Unsafe Temperatures
Penalty
Summary
Food and drink were not maintained at safe and appetizing temperatures for supper service. Review of the facility’s Dining Services Food Preparation Guideline stated that no foods were to remain unrefrigerated for more than one hour and identified the temperature danger zone as 41 degrees F to 135 degrees F. The facility’s Food Temperature Recording Log for the supper time-of-service showed chicken salad at 39 degrees F, tuna salad at 38 degrees F, egg salad at 39 degrees F, fruit at 38 degrees F, and soup at 181 degrees F. Observation of the St. [NAME] Pavilion Unit at 5:30 PM showed dinner trays delivered to the unit, and at 5:45 PM five supper trays remained on the cart for residents who were in a meeting. At 6:00 PM, the Assistant Dietary Manager observed a tray with no meal slip and found applesauce at 74 degrees F, water at 75 degrees F, lemonade at 74 degrees F, raspberry sherbert melted at 23 degrees F, fresh fruit at 70 degrees F, chicken salad at 71 degrees F, tuna salad at 69 degrees F, egg salad at 70 degrees F, and broccoli cheddar soup at 101 degrees F. The Assistant Dietary Manager stated hot food should be held at 135 degrees F on the steam table and said his expectation was for hot food to reach the units at 100 degrees F and cold food at 55 degrees F, and that the plates were not cold because staff forgot to take them out of the warmer prior to service. The DON and Administrator stated that if a resident was not present for the meal, the tray should be returned to dietary and a new tray sent to the resident.
Failure to Provide Required Two-Person Hoyer Lift Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were provided to prevent accidents for one resident. The resident had diagnoses of ESRD, diabetes, and depression, and the care plan directed that transfers required a mechanical lift with two staff assistance. The facility’s policies stated the environment should remain free of accident hazards as possible and that two staff members must be used to transfer residents with a mechanical lift. The investigation found that the incident occurred when the resident was in a Hoyer lift and staff left the resident suspended in the air while one aide went to get additional assistance. The resident stated that two aides walked out of the room while she was in the lift. A CNA reported entering the room and seeing the resident up in the Hoyer lift, and the DON stated the investigation determined two CNAs left the resident in the lift and walked out of the room. Interviews with staff showed conflicting accounts, but the DON confirmed the resident was left in the lift and that the involved aides were terminated.
Failure to Maintain Resident Dignity During Catheter Care, Meals, and Staff Communication
Penalty
Summary
The facility failed to treat residents with respect and dignity and to care for them in a manner and environment that maintained or enhanced quality of life for 3 of 29 sampled residents. Facility policies stated that residents with indwelling catheters were to have privacy bags and that catheter drainage bags were to be covered at all times while in use, and that resident privacy and dignity were to be maintained during care and mealtimes. For one resident with diagnoses including heart failure, overactive bladder, and other bladder disorders, the facility admitted the resident with an indwelling suprapubic catheter and care planned the resident for catheter integrity. Observations on three separate occasions showed the catheter bag did not have a dignity cover and was on the floor on the door side of the bed. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and staff interviews confirmed that indwelling catheters were expected to have a dignity bag, although one CNA stated she had not seen a dignity bag in the facility and did not know where they were kept. During dinner meal service, one resident with diagnoses including dementia, stroke, and anxiety was seated at a table with five other residents but did not receive her tray until 23 minutes after the first trays were delivered to the unit. The resident stated she always received meals later than her tablemates. In a separate dining room observation, a CNA loudly called another resident a feeder in front of staff and residents. Staff interviews reflected that calling a resident a feeder out loud was a dignity issue, and the Administrator stated it was not her expectation for staff to use that term and that it was a dignity issue.
Failure to Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that all residents were informed and provided written information about the right to formulate an advance directive for 2 of 29 sampled residents, R2 and R37. Review of the facility policy showed residents were to receive information and education about advance directives on admission, with the facility identifying whether an advance directive existed and whether the resident wished to formulate one. The policy also stated advance directive copies were to be obtained, placed in the EMR, and readily retrievable. However, the EMR for both residents contained a signed DNR document in the advance directive tab, but there was no documentation showing that advance directive information had been provided. R2 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, cerebral infarction, and malignant neoplasm of the larynx. His admission MDS showed no score for cognitive patterns, and he was non-verbal during surveyor interview attempts. R37 was admitted with diagnoses including psychotic disturbance, mood disturbance and anxiety, monoplegia following cerebral infarction, and bipolar disorder; her quarterly MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. Both residents' care plans referenced advance directives and identified them as DNR, but the facility could not produce documentation of advance directive information for either resident when requested by the surveyor.
Failure to Resolve and Document Missing-Item Grievances
Penalty
Summary
The facility failed to provide resolutions and/or documentation of resolutions for missing-item grievances raised in Resident Council for 2 of 14 sampled residents, R52 and R57. Review of the facility’s Resident Rights policy and Complaint and Grievance Policy showed the facility was responsible for protecting resident rights, investigating grievances, tracking them to conclusion, and issuing written grievance decisions to residents. However, the Resident Council minutes from the meeting held on 08/21/2025 documented that R52 reported missing a white tee shirt, a polo shirt, and one pair of navy-blue back-flap slacks, and that no resolution had been provided. The same minutes documented that R57 reported missing a pair of white leather gym shoes for eight months, also with no resolution. Record review showed both residents were cognitively intact, with R52 having a BIMS score of 15 of 15 and diagnoses including multiple sclerosis, neuromuscular scoliosis thoracolumbar region, and cranial nerve disorders, and R57 having a BIMS score of 14 of 15 with diagnoses including unspecified convulsions, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and general anxiety. Facility forms showed R52 had previously reported missing clothing items on 05/28/2025, 08/26/2025, and 09/15/2025, each with no resolution given, including a report from the resident’s sister about the missing slacks. R57’s Missing Property form dated 05/09/2025 showed two clear shower caddies were replaced, but her white gym shoes were not replaced and no resolution was given. During interviews, the former SSD stated grievances were to be documented immediately, investigated, and resolved within one to two business days, while the Administrator stated older grievances were being reviewed and that staff should document grievances and send them to her office for investigation.
Failure to Provide Written Transfer, Discharge, and Bed-Hold Notices
Penalty
Summary
The facility failed to notify residents and their representatives in writing, in a language and manner they understood, of emergency transfers or discharges and the reasons for the move as soon as practicable. The required notices were also missing key information, including the date and location of the transfer, the resident’s appeal rights, and the contact information for the state Long-Term Care Ombudsman. This deficient practice affected 3 of 3 sampled residents: R6, R10, and R66. R6 was admitted with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus with hyperglycemia, and acute kidney disease, and later had a BIMS score of 2 of 15, indicating severe cognitive impairment. R6 was hospitalized after a fall that resulted in a right hip fracture and status post ORIF. The EMR contained no transfer/discharge notice or bed hold notice. R6’s family member stated the facility called about the transfer and verbally discussed the bed hold option, but she could not remember receiving a written letter. R10 was admitted with diagnoses including Alzheimer’s disease, bipolar disorder, and hypertension, and had a BIMS score of 7 of 15, indicating severe cognitive impairment. R10 was sent to the emergency room for a mental health evaluation due to behaviors, and the EMR contained no transfer/discharge notice or bed hold notice. R10’s family member stated he never received a bed hold or transfer/discharge letter, although the facility did call and discuss both. R66 was admitted with diagnoses including Alzheimer’s disease, dementia, and repeated falls, and was sent to a mental health facility for behaviors. Her EMR also contained no transfer/discharge notice or bed hold notice, and her family member stated he did not receive a bed hold or transfer/discharge letter and was only told by phone that she was being sent to the hospital.
Failure to Maintain Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis received safe, appropriate dialysis-related care and services consistent with professional standards, the resident’s care plan, and the facility’s dialysis communication process. The resident was admitted with ESRD, diabetes, and depression, and the quarterly MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The care plan included hemodialysis and an intervention to provide and receive written communication with the dialysis center for every treatment. The facility’s dialysis policy stated that residents receiving hemodialysis would have ongoing assessment and monitoring before and after dialysis, including monitoring for complications, and ongoing communication and collaboration with the dialysis facility. The dialysis agreement required the facility to ensure appropriate medical and other information accompanied the resident to the dialysis center. The facility’s dialysis communication form was intended to be completed by the facility before transport and by the dialysis clinic after treatment, with the completed form returned to the facility. Survey findings showed the communication process was not consistently followed. The resident stated she was not usually given a form to take to dialysis. An RN stated she had never heard of the dialysis form, had never sent anything with the resident to dialysis, and had never received anything back from dialysis or communicated with the clinic. Another RN stated the forms were used sporadically and that the dialysis center did not fill them out and/or the resident did not bring them back. The dialysis clinic RN stated the resident came with a form sometimes but not consistently, and the form was not available for all dialysis days. The DON and Administrator stated the forms were important for continuity of care and expected them to be completed, but they did not know why they had not been completed and had not educated staff or audited completion.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with accepted professional principles. On the [NAME] Unit medication cart, surveyors observed an unlabeled strip of Dulcolax (bisacodyl) tablets in a commercial blister pack with nine pills missing and 16 remaining, with a date written on tape on the back, stored with R82's medications. On the same cart, R52's albuterol inhalation aerosol HFA was stored with oral medications. On the St. [NAME] Unit medication cart, surveyors observed four insulin pens stored loosely, without a full label and not in separate packaging. Staff interviews reflected that insulin pens were expected to be stored in individual bags with the resident's label, kept in the medication cart or refrigerator until use, and separated from other medication routes for infection control and to prevent cross contamination. The DON, unit manager, RN, and LPN all stated medications should be clearly labeled and stored separately by route, including insulin pens in their own bags.
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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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 23 | 0 |
| Rosedale Green | 3.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.