Carmel Manor: Fall Protocol Failures Cause Actual Harm - KY
Nine months later, when federal inspectors asked to see the checklist, the Director of Nursing said she couldn't find it.
The resident, identified in inspection records as Resident 13, was already care planned as a fall risk before the June fall. A licensed practical nurse told inspectors that staff had responded to her restlessness with increased checks and activities. But after she fell, the care plan wasn't revised. No new interventions were added. The MDS Nurse, who oversees care planning at the facility, told inspectors on March 11, 2025 that she was unsure why.
"Every resident is at risk for falls," the MDS Nurse said, "and residents with a history of falls required careful monitoring." She said care plans should be revised after a fall, with new interventions put in place to try to prevent the next one. She acknowledged the care plan for Resident 13 should have been updated after the June 2024 incident. She could not explain why it wasn't.
The Director of Nursing, interviewed on March 13, laid out what the protocol was supposed to look like: the nurse on duty completes the Fall Checklist step by step, submits it to the DON, and the Interdisciplinary Team convenes to review what happened and determine what changes to make. She described it as a structured process with clear accountability at each stage.
Then she said she couldn't find the checklist for Resident 13's fall.
She also told inspectors she kept Interdisciplinary Team notes in a physical binder rather than in the facility's electronic medical records system. That detail matters: it means the documentation trail for fall reviews exists, if at all, only on paper, in a binder, held by one person.
Inspectors rated the violation as causing actual harm, not merely potential harm. The distinction is significant. Actual harm means the failure wasn't theoretical. Resident 13 was a known fall risk. She fell. The system designed to respond to that fall and protect her afterward did not function. The care plan sat unchanged.
The Interim Administrator, interviewed on the final day of the inspection, March 15, said it was her expectation that staff would follow fall policies and revise care plans for resident safety. She did not address why, in this case, they hadn't.
What the inspection record shows is a gap between what a facility says its process is and what actually occurred when that process was needed. The Director of Nursing could describe the Fall Checklist protocol in detail. She could not produce the checklist. The MDS Nurse understood that post-fall care plan revisions were required. She could not explain why none were made for Resident 13 after June 2024.
By the time inspectors arrived in March 2025, more than eight months had passed since the fall. Resident 13's care plan had not been updated. The checklist was missing. The IDT notes, if they existed, were in a binder.
The facility was cited under the federal standard requiring nursing homes to develop and implement comprehensive care plans that address each resident's needs, and to revise those plans when a resident's condition or circumstances change. Carmel Manor is located at 100 Carmel Manor Road in Fort Thomas.
What the inspection record does not say is whether Resident 13 fell again in those eight months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carmel Manor from 2025-03-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 4, 2026 · Our methodology
Carmel Manor in Fort Thomas, KY was cited for violations during a health inspection on March 15, 2025.
Nine months later, when federal inspectors asked to see the checklist, the Director of Nursing said she couldn't find it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.