Cycle 1
Health 2025-12-01 · Fire 2025-12-01
27 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fort Thomas, KY
Carmel Manor
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $312,265 in total fines with 27 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
100 Carmel Manor Road, Fort Thomas, KY
(859) 781-5111
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Carmelite Sisters For The Aged & Infirm
Operator or chain grouping
Approved since
1990-07-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing
LPN hours / resident day
1.01
Licensed practical nurse staffing
Aide hours / resident day
2.63
Nurse aide staffing
Weekend hours
4.15
Weekend nurse staffing
RN turnover
62%
Annual RN turnover
Total nurse turnover
74%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
94.3%
3.3 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.8%
0.1 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
15.2%
10.3 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.0% |
6.7%
1.3 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
29.6%
4.1 pts better
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.6% |
17.6%
4 pts better
|
16.7%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.1% |
17.3%
8.8 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.1% |
15.6%
13.5 pts worse
|
14.9%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.7%
0.5 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.6% |
19.8%
16.8 pts worse
|
19.8%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.5%
0.8 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
83.8%
10 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
13.9%
6.2 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.1% |
1.8%
3.3 pts worse
|
1.6%
3.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
83.6%
2.4 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.7% |
24.5%
11.2 pts worse
|
23.9%
11.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-05 · Fire 2023-05-05
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-03-17 · Fire 2022-03-17
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-01
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-12
F · Potential for more than minimal harm
2023-05-05
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-05-05
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-08-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-01
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-12-16
F · Potential for more than minimal harm
2025-12-01
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-12-16
F · Potential for more than minimal harm
2025-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-16
F · Potential for more than minimal harm
2025-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-01
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-01
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-16
J · Immediate jeopardy
2025-07-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-04
J · Immediate jeopardy
2025-07-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-04
J · Immediate jeopardy
2025-07-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-04
J · Immediate jeopardy
2025-07-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-04
J · Immediate jeopardy
2025-07-24
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-04
G · Actual harm
2025-07-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-16
F · Potential for more than minimal harm
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-07-24
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-09-04
J · Immediate jeopardy
2025-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-16
J · Immediate jeopardy
2025-03-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-16
G · Actual harm
2025-03-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-16
E · Potential for more than minimal harm
2023-05-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-05
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-01
G · Actual harm
2022-03-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-22
G · Actual harm
2022-03-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-04-22
F · Potential for more than minimal harm
2022-03-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-04-22
Penalties and ownership
What sits behind the stars
$291,840
2025-07-24
Fine
Fine · fine $291,840
Fine
$0
2025-07-24
Payment Denial
Payment Denial · denial start 2025-08-28 · 110 days
110 day denial
$10,000
2025-03-15
Fine
Fine · fine $10,000
Fine
$10,425
2025-03-15
Fine
Fine · fine $10,425
Fine
$0
2025-03-15
Payment Denial
Payment Denial · denial start 2025-04-12 · 4 days
4 day denial
Ownership
Baniewicz, Mary
Corporate Director · Individual
Brauley, Jeffrey
Corporate Director · Individual
Brauley, Jeffrey
Corporate Officer · Individual
Brown, Ann
Corporate Director · Individual
Desmond, Walter
Corporate Director · Individual
Dominick, Kathleen
Corporate Director · Individual
Gathers, Patricia
Corporate Officer · Individual
Haas, Adam
Corporate Director · Individual
Haley, Margaret
Corporate Director · Individual
Haley, Margaret
Corporate Officer · Individual
Itticheria, Achamma
Operational/Managerial Control · Individual
Klein, Matt
Corporate Director · Individual
Mccartney, Ann
Corporate Director · Individual
Mccauley, Patrick
Corporate Director · Individual
Millette, Catherine
Corporate Director · Individual
Millette, Catherine
Corporate Officer · Individual
Mullen, Bobette
Corporate Director · Individual
Pfeffer, Theresa
Corporate Director · Individual
Pfeffer, Theresa
Corporate Officer · Individual
Quinn-Sexton, Jena
Operational/Managerial Control · Individual
Quinn-Sexton, Jena
Corporate Officer · Individual
Saalfeld, Thomas
Corporate Director · Individual
The Carmelite System Inc
Operational/Managerial Control · Organization
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