Liberty Nursing Center of Colerain: Fall Investigation Failures - OH
When inspectors arrived at the facility on Livingston Road in August, the fall investigation still had not been completed. The lapse was not a matter of interpretation. The facility's own policy, a document titled Falls-Clinical Protocol dated March 2018, said staff and a practitioner should begin identifying possible causes within 24 hours of a fall. Based on that assessment, the policy continued, staff and the physician would identify what investigations were needed to prevent another fall and address the risks of serious consequences from falling.
None of that happened.
The inspection, completed August 27, 2025, captured the violation under a complaint investigation. Not one complaint. Eight.
Federal records list eight separate complaint numbers tied to this deficiency at Liberty Nursing Center of Colerain, a facility at 8440 Livingston Road in Cincinnati. The complaints came from multiple sources, filed at different times, all funneling toward the same finding: a resident fell, and the facility did not do what its own written protocol required.
The harm level assigned to the deficiency was minimal harm or potential for actual harm. The number of residents affected was listed as few.
Those are regulatory classifications. What they describe is a nursing home that had a policy for exactly this situation, had been told about the failure through complaint after complaint, and still had not closed the gap between what the paperwork promised and what staff actually did.
Falls in nursing homes are not minor events. Older adults, particularly those with conditions common in long-term care settings, face serious consequences when they fall, including fractures, head injuries, and a cascade of complications that can follow them for months. The entire purpose of a fall investigation is to understand what went wrong and reduce the chance it happens again. Without one, the next fall arrives without any of the information the last one could have provided.
Liberty Nursing Center of Colerain's own protocol acknowledged this. It directed staff to identify pertinent investigations that would address the risks of clinically significant consequences of falling. That language, written into the facility's own policy seven years before this inspection, was the standard the facility failed to meet.
Eight complaints is not a rounding error. It suggests that people, whether residents, family members, or staff, noticed something wrong and reported it, repeatedly, through official channels. Each complaint number in the federal record represents someone deciding the situation was serious enough to document. The inspection finding confirmed they were right.
The deficiency was cited at the minimal harm level, which in the federal rating system means inspectors believed the situation had not yet caused serious injury. That determination reflects what inspectors could document, not a guarantee of what the resident experienced in the weeks and months after the fall went uninvestigated.
For the residents at Liberty Nursing Center of Colerain, the gap in this investigation meant something specific: whatever caused the April 15 fall, whatever in the environment or the care plan or the resident's condition contributed to it, was never formally examined. The questions the protocol required someone to ask within 24 hours were still unanswered when inspectors walked through the door more than four months later.
The facility's plan of correction was not included in the inspection materials reviewed. CMS directed anyone seeking that information to contact the nursing home or the state survey agency directly.
What the record contains is the finding itself, and the eight complaints that preceded it, and the facility's own words about what should have happened within a day of a resident hitting the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liberty Nursing Center of Colerain Inc from 2025-08-27 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 2, 2026 · Our methodology
LIBERTY NURSING CENTER OF COLERAIN INC in CINCINNATI, OH was cited for violations during a health inspection on August 27, 2025.
When inspectors arrived at the facility on Livingston Road in August, the fall investigation still had not been completed.
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.