Carmel Manor

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

35.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 18.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 95 beds and averages 86.8 residents a day — about 91% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.75 hrs/resident/day on weekends vs 4.15 on weekdays — 10% thinner on weekends. RN hours go from 0.82 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 79% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

38 citations, most serious first. The 21 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · J2025-07-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to take steps to prevent sexual abuse from occurring for 2 of 15 sampled residents, Resident (R) 2 and R3.R2 and R3, two cognitively impaired residents, were observed having intercourse. Instead of separating the residents, staff were told to close the resident's door and provide the cognitively impaired residents privacy. Staff stated the residents were not assessed to have the ability to consent to the sexual activity, and interviews with staff revealed they did not know what to do for R2 and R3.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F600) at the highest Scope and Severity (S/S) of a J.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-24 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the facility's investigation, review of the facility's job descriptions, and review of the facility's policy, the facility failed to develop and implement policies and procedures to prohibit and prevent abuse and failed to establish policies and procedures to thoroughly investigate allegations of abuse for 2 of 15 residents, Resident (R) 2 and R3. R2 and R3, both cognitively impaired, were observed having sexual intercourse.Additionally, the facility failed to promote a culture of safety and open communication in the work environment through prohibiting retaliation against an employee for reporting abuse. The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F607) at the highest Scope and Severity (S/S) of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-07-24 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility's job descriptions, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure, in response to an incident of witnessed sexual abuse, it had evidence of a thorough investigation, to include reporting the incident to the state agency timely, and protecting the residents during and after the investigation for 2 of 15 sampled residents, Resident (R) 2 and R3. On 06/30/2025, R2 and R3 were found by staff in R3's bed naked. The residents were not separated immediately, and based on interview, the room door was closed. Review of medical records and interviews revealed immediate assessments had not been performed. Additional review and interview revealed the families and medical providers of R2 and R3, authorities, and state agencies had not been contacted immediately on 06/30/2025.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-24 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop person-centered care plan interventions for 4 of 7 sampled residents, Resident (R) 1, R2, R3, and R11. 1. The facility failed to follow interventions placed on R1's Comprehensive Care Plan [CCP] and Kardex to prevent an accident on 06/19/2025, resulting in a compound fracture of R1's right lower extremity, which required surgical intervention.2. The facility failed to develop R11's CCP with person-centered interventions to prevent falls for R11. On 07/14/2025, R11 fell out of bed and sustained a right shoulder fracture.3. The facility failed to develop R2's and R3's CCP with person-centered interventions to address the residents' behaviors, assessments, ability to consent to sexual activity, or supervision needs following the sexual encounter. R2 and R3, both cognitively impaired were found in bed naked on 06/30/2025 and engaging in sexual activity. Staff stated the residents were not assessed to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-07-24 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident by failing to follow the abuse policy and procedures related to protecting residents and conducting a thorough investigation of abuse after two cognitively impaired residents were observed having sexual intercourse, Resident (R) 2 and R3.On 06/30/2025, R2 and R3 were found in R3's bed naked, engaging in sexual activity, and neither had been assessed for ability to consent to activity.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.70 Administration (F835) at the highest Scope and Severity…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-03-15 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights and provide services required to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 sampled residents, Resident (R)1 and R24. 1. On 02/25/2025, R1, who resided on the facility's locked Memory Care Unit (MCU), and was care planned to wear a wanderguard (a monitoring device that triggers door alarms to alert staff when a resident was near a door or going out a door) was observed entering the facility through the main door which was equipped with an alarming device. However, the door did not alarm when R1 entered the facility. During interviews with the MCU staff, they stated they had last seen the resident at approximately 4:00 PM, and were unaware R1 left the building without staff's knowledge until they received a phone call from Receptionist 2, alerting them R1 was entering the facility. Receptionist 2 stated R1 was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-03-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the RoamAlert Resident Safety User Guide, and review of the facility's documents and policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and properly functioning assistance devices to prevent unsafe wandering, elopement, and falls for 3 of 11 sampled residents, Resident (R)1, R12, and R13. 1. R1's Clinical orders, initiated 05/20/2024, revealed orders for the resident to wear a wanderguard bracelet (an electronic device that caused an alarm to sound when the resident tried to exit a door that had an accompanying device installed) to his right wrist and to check every shift. Per R1's Progress Note, dated 06/25/2024, R1 was exit-seeking, went outside the exit door, and was brought back into the facility immediately. However, per the 06/25/2024 note, the wanderguard was not on R1's right wrist upon staff bringing the resident back inside. Subsequently, on 02/25/2025, R1 who resided on the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed for accidents, Resident (R)1, R7, and R11.1) On 06/19/2025, R1 sustained a compound fracture to right lower extremity during a transfer, requiring surgical interventions. However, review of the facility's investigation, they determined it was an injury of unknow origin and the cause was unable to be determined.2) On 07/14/2025, R11 was found in her room on the floor and was transferred to local hospital. Hospital records revealed R11 sustained a broken shoulder.3) On 07/09/2025, observation during an interview with R7 revealed a medication cup with 2 pills in it on the overbed table. Additional observation revealed one pill lying on the over bed table. During an immediate interview, Registered Nurse (RN)3 stated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-03-15 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for 2 of 12 sampled residents, Resident (R)12 and R13. 1. On 06/07/2024, R12 was transferred without the use of a gait belt, as per policy. The resident sustained wounds to the left knee, and left arm, and bruising with scratches on the left ribcage. Additionally, a CT of the Chest performed on 06/08/2024, revealed an age-indeterminate nondisplaced left 8th rib fracture. R12's care plan was updated on 06/08/2024 to state the resident required extensive assistance by two staff to move between surfaces; however, the CCP was not revised to include an intervention for the use of a gait belt during transfers. 2. R13 sustained 6 falls from 03/04/2024 through 03/09/2025. However, there was no documented evidence the CCP was revised with new interventions to prevent recurrence. On 06/06/2024, R13 sustained an unwitnessed fall,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-03-17 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive, person-centered care plan to meet each of the medical, nursing, mental and psychosocial needs identified on the resident's comprehensive assessment. The facility also failed to ensure the care/services were furnished so that residents attained or maintained their highest practicable physical, mental and psychosocial well-being, for three (3) of twenty-three (23) sampled residents (Residents #41, #22 and #14). Resident #41's care plan instructed staff to use a mechanical lift for transfers, however a State Registered Nurse Assistant (SRNA) stated she transferred the resident with a stand and pivot transfer, instead of using a mechanical lift. Resident #41 received a laceration to the left lower extremity which required twelve (12) sutures to repair. Resident #22's care plan instructed staff to have a dycem pad (a non-slip pad used to prevent falling or sliding out…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident received proper care and/or services to ensure he/she was free from accidents and hazards for two (2) of twenty-three (23) sampled residents (Resident #41 and Resident #22). The facility assessed Resident #41 to be an extensive assist of two (2) staff for transfers with a mechanical lift: However, State Registered Nurse Aide (SRNA) #10 used a stand and pivot, one (1) person transfer on 01/05/2022 which resulted in a laceration to Resident #41's left lower leg. Resident #41 was sent to the Emergency Department and received twelve (12) sutures. Resident #22 sustained a non-injury fall on 02/14/2022. Resident #22 had orders for his/her wheelchair to have a dycem cushion to prevent falls. After the fall, it was discovered Resident #22 had not been in his/her wheelchair which had the dycem cushion/pad. Resident #22 had been sitting in a wheelchair without a dycem…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-01 · tag F0802 — failed to prepare enough nourishing food — widespread
  Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Observation on 09/18/2025 revealed nursing staff instead of dietary staff took breakfast tray carts to the units and served the residents, and resident roommates were regularly served meals more than 27 minutes apart, which angered the resident who had to wait. Also, in an interview with the Dietary Manager on 09/18/2025, he stated he only had nine current dietary employees, and it took seven each day to perform the required dietary functions. This deficient practice affected 80 residents who received their meals from the kitchen. The findings include:Review of the facility's policy titled, Serving a Meal, dated 08/2024, revealed residents should be encouraged to eat in the dining room; however, requests to remain in the room should be honored.1. Observation on 09/18/2025, beginning at 8:00 AM, revealed in the kitchen the breakfast tray line was started to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-01 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of the facility's policies, the facility failed to provide meals at regular times comparable to normal mealtimes in the community or to which they were accustomed and preferred. Observations on 09/16/2025, 09/17/2025, 09/18/2025, and 09/19/2025 revealed breakfast, lunch, and dinner meals were delivered late, some an hour later than the expected time. During subsequent interviews with residents and families, they reported delayed meals negatively altered the remainder of the residents' day and evening routines, which upset the residents for 5 of 14 sampled residents, Resident (R) 26, R28, R51, R62, and R64.The findings include:Review of the facility's policy titled, Resident Rights-Promoting and Maintaining Resident Dignity during Mealtimes, effective date 03/16/2023, revealed the practice of the facility was to treat each resident with respect, dignity, and give care in a manner that maintained or enhanced quality of life, recognizing each resident's individuality and protecting the rights of each resident. Further review revealed staff…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's document and policy, the facility failed to store and prepare food in a safe manner. Observation on 09/16/2025 and 09/17/2025 revealed uncovered kitchen utensils and equipment. Also, observation on 09/16/2025 of the resident kitchen unit refrigerators revealed two of the four had resident food products not labeled with the resident's name, date received, and the identity of the food product. The deficient practice had the capability of affecting 80 residents who received food from the kitchen or all residents that had additional food left in the unit kitchenette refrigerators. The findings include:Review of the facility's policy titled, Food: Safe Handling for Foods from Visitors, dated 09/2017, revealed residents would be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. The policy stated when food items were intended for later consumption, the responsible facility staff member would ensure…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-01 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 7 out of 52 sampled residents, Resident (R) 3, R15, R49, R55, R58, R68, and R82. The findings include:Review of the CDC Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. It stated staff should ensure the proper selection and use of personal protective equipment (PPE) based on the nature of the patient/resident interaction and potential for exposure. According to the guidelines, regular and proper…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-01 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's document and policy, the facility failed to provide food at safe serving temperatures. Observation on 09/16/2025 of residents' supper trays on the cart revealed the foods to be served were not at safe temperatures for 5 of 18 sampled residents, Resident (R)14, R46, R57, R63, and R81. The findings include:Review of the facility's policy titled, Dining Services Food Preparation Guideline, dated 07/01/2024, revealed no foods were to remain unrefrigerated for a period of more than one hour to prevent the food's temperature from being in the danger zone, which was 41 degrees Fahrenheit (F) to 135 degrees (F). Per the policy, the Hazard Analysis Critical Control Point (HACCP), was a method that identified the period when potentially hazardous food, (meat, milk, egg products, and pudding etc.) were most likely to be in the temperature's danger zone of 41 degrees F to 135 degrees F. The policy stated the temperature danger zone provided the ideal condition…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-01 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 29 sampled residents, Resident (R) 15, R16, and R80. The findings include: Review of the facility's policy titled, Catheter Care, revised date 04/24/2025, revealed residents with indwelling catheters maintained their dignity and privacy. The policy stated, Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of the facility's policy titled, Resident Rights-Promoting and Maintaining Resident Dignity, dated 03/16/2023 and revised on 06/16/2025, revealed it stated, It is the practice of this home [facility] to provide and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residents'…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-01 · tag F0578 — failed to honor advance directives / code status — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure that all residents were informed and provided written information concerning the right, at the resident's option, to formulate an advance directive for 2 of 29 sampled residents, Resident (R) 2 and R37. Review of the residents' electronic medical records revealed there was no advance directive information for R2 and R37, and the facility did not produce documentation demonstrating advance directive information had been provided.The findings include: Review of the facility's policy titled Advance Directive and Care Planning Policy, effective 04/21/2024, revealed the facility would provide residents with information and education of their rights as well as to promote the residents' right to formulate an advance directive and to assist the resident in the exercise of those rights. Further review revealed resident choices would be incorporated into their plan of treatment, care, and services. Continued review revealed upon admission, the facility would identify if the resident had an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-01 · tag F0585 — failed to handle grievances — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of the facility's policies, the facility failed to provide resolutions and/or provide documentation on resolutions related to reported missing items in the Resident Council meeting on 08/21/2025 for 2 out of 14 sampled residents, Resident (R) 52 and R57. The findings include:Review of the facility's policy titled, Resident Rights, dated 04/21/2024, revealed the facility would protect and promote the rights of the resident and afford each resident his or her basic right to be treated with dignity and respect. Per the policy, the facility would ensure all residents were afforded their right to a dignified existence, self-determination, and respect. The policy also stated all personnel were required to protect and promote the rights of each resident, as well as encourage and assist each resident in the fullest possible exercise of their rights. Review of the facility's policy titled, Complaint and Grievance Policy, effective 03/14/2024, revealed the Administrator was responsible to ensure the investigation of grievances and complaints. Per…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-01 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. Additional information the resident and the resident's representation were not given, and which should have been on the notice included the date, location for 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, Resident (R) 6, R10, and R66. The findings include: Review of the facility's policy titled, Discharge and Transfer from the Facility, effective date 04/21/2024, revealed for emergency transfers such as when a resident was transferred on an emergency basis to an acute care facility, that type of transfer was considered to be a facility-initiated transfer, and a notice of transfer must be provided to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, review of the facility's investigation, and review of the facility's policies, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 23 sampled residents, Resident (R) 7.The findings include:Review of the facility's policy titled, Accidents and Supervision, no date, revealed it stated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.Review of the facility's policy titled, Resident Care-Safe Resident Handling/Transfers, dated 10/01/2024, revealed it stated, It is the policy of this home to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy also revealed two staff members must be used to transfer residents with a mechanical lift. Review…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$305,116 in federal fines across 3 penalties. 2 Medicare payment denials on record.

• $291,840 — penalty dated 2025-07-24
• $6,500 — penalty dated 2025-03-15
• $6,776 — penalty dated 2025-03-15
• Medicare payment denial — starting 2025-08-28 for 110 days
• Medicare payment denial — starting 2025-04-12 for 4 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CARMELITE SISTERS FOR THE AGED & INFIRM — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 27 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $478K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KY