27 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fort Thomas, KY
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
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
Chain footprint
8 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.65
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
9,687
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.31
Baseline 19.41% · Performance 20.83% · Measure score 1.31 · Achievement 1.31 · Improvement 0
Healthcare-associated infections
0.76
Baseline 7.36% · Performance 7.61% · Measure score 0.76 · Achievement 0.76 · Improvement 0
Total nurse turnover
0
Baseline 73.33% · Performance 72.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
7.08
Baseline 4.36 hours · Performance 5.09 hours · Measure score 7.08 · Achievement 7.08 · Improvement 4.66
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 5.68% · Lower 95% interval 6.74% |
| Discharge to community | 35.65% |
50.57%
14.9 pts worse
|
Worse than the National Rate · Eligible stays 77 · Observed rate 28.57% · Lower 95% interval 25.36% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 29.63% |
53.69%
24.1 pts worse
|
Numerator 8 · Denominator 27 |
| Discharge mobility score | 14.81% |
50.94%
36.1 pts worse
|
Numerator 4 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 42 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 9.8% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 10.22% |
42%
31.8 pts worse
|
Numerator 23 · Denominator 225 |
| Discharge function score | 18.52% |
56.45%
37.9 pts worse
|
Numerator 5 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
| 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 · Adjusted 2.3 · Observed 2.4 · Expected 2.0 · Used in QM five-star |
| 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 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 98.8% · Q3 96.5% · Q4 95.0% · 4Q avg 97.6% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 3.7% · Q2 3.6% · Q3 3.5% · Q4 5.0% · 4Q avg 3.9% · Used in QM five-star |
| 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 · Q1 5.3% · Q2 5.3% · Q3 4.4% · Q4 4.7% · 4Q avg 4.9% |
| 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 · Q1 10.4% · Q2 12.1% · Q3 7.6% · Q4 1.6% · 4Q avg 8.0% |
| 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 · Q1 26.1% · Q2 24.3% · Q3 23.2% · Q4 28.4% · 4Q avg 25.5% |
| 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 · Q1 15.1% · Q2 12.1% · Q3 14.5% · Q4 12.7% · 4Q avg 13.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 37.2% · Q2 16.3% · Q3 30.7% · Q4 16.3% · 4Q avg 26.1% · Used in QM five-star |
| 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 · Q1 46.2% · Q2 16.9% · Q3 29.5% · Q4 23.8% · 4Q avg 29.1% · Used in QM five-star |
| 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 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 2.5% · Q3 4.9% · Q4 1.3% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 38.5% · Q2 33.1% · Q3 45.1% · Q4 28.9% · 4Q avg 36.6% |
| 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 · Q1 1.9% · Q2 5.7% · Q3 6.2% · Q4 5.1% · 4Q avg 4.7% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 93.8% · Q4 75.0% · 4Q avg 93.8% |
| 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 · Adjusted 7.7% · Observed 8.1% · Expected 11.7% · Used in QM five-star |
| 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 · Q1 9.1% · Q2 0.0% · 4Q avg 5.1% · Used in QM five-star |
| 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 · 4Q avg 86.0% |
| 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 · Adjusted 35.7% · Observed 37.8% · Expected 25.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
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
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-12
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
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-12
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-01
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-08-01
Inspection history
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-12-16
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
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-16
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-16
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
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
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-16
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-12-16
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
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
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-04
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-04
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
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-16
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-16
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-16
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
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-16
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-16
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-16
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-16
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
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
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-01
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-01
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
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-01
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-04-22
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-22
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-04-22
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
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-22
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-04-22
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
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
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-04-22
Penalties and ownership
Fine · fine $291,840
Fine
Payment Denial · denial start 2025-08-28 · 110 days
110 day denial
Fine · fine $10,000
Fine
Fine · fine $10,425
Fine
Payment Denial · denial start 2025-04-12 · 4 days
4 day denial
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
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