Liberty Nursing Center: Ignored Ankle Fracture - OH
Resident #80 returned to Liberty Nursing Center of Colerain from the hospital on June 8 with her left ankle in a splint after orthopedic doctors treated her fracture. She would remain at the facility until August 2, but inspectors found no evidence that staff ever developed a plan to care for her injury.
The 67-bed facility's own policy from January 2018 states that medical devices "should be reflected on the care plan," and if a device cannot be removed, doctor's orders should specify that. Staff ignored both requirements.
Hospital records show Resident #80's ankle fracture was discovered during a June 6-8 hospital stay. An x-ray revealed the break, and orthopedic specialists splinted her left lower leg before scheduling follow-up care for June 10. The resident had been living at Liberty Nursing Center since December 2022, managing end-stage kidney disease, diabetes, and chronic lung disease.
When she returned from the hospital, nothing changed in her care documentation. Federal inspectors found no physician orders for her fractured ankle from June 8 through August 2. No orders for splint care. No care plan updates acknowledging the injury existed.
The Assistant Director of Nursing confirmed the obvious during an August 19 interview. Yes, Resident #80 had a splint on her left leg when she returned from the hospital. No, there were no orders or care plan reflecting its presence or the care it required.
Six days later, Registered Nurse #300 told inspectors the same thing. The resident's care plan ignored her ankle fracture, her splint, and any treatment the injury might need.
Resident #80 was cognitively intact according to her July assessment, meaning she was fully aware of her condition and the apparent indifference to it. The same assessment noted she needed help with mobility and toileting – tasks that would be significantly complicated by an untreated ankle fracture and medical device wrapped around her leg.
The failure represents more than paperwork negligence. Care plans drive daily nursing activities, medication schedules, and therapy goals. Without documentation of her fracture, nursing assistants had no guidance on how to safely move her. Physical therapists had no indication of weight-bearing restrictions. Nurses had no orders governing splint maintenance or skin monitoring underneath the device.
Medical device-related pressure injuries are a recognized hazard in nursing homes. Splints, braces, and similar equipment can cause skin breakdown if not properly monitored and adjusted. Liberty Nursing Center's own policy acknowledged this risk, requiring care plans to address medical devices specifically.
The resident lived with this documentation gap for nearly eight weeks. During that time, she needed assistance with basic mobility while managing a fractured ankle that staff had essentially forgotten existed in any official capacity.
Federal inspectors classified the violation as causing minimal harm to few residents, but the finding illuminated a broader breakdown in care coordination. When hospitals discharge patients with new medical needs, nursing homes must integrate those conditions into existing care plans. Liberty Nursing Center simply didn't.
The inspection occurred in response to a complaint filed with state regulators. The specific nature of that complaint was not detailed in federal records, but it led investigators to examine care planning practices at the facility.
Resident #80 was discharged from Liberty Nursing Center on August 2, just weeks before federal inspectors arrived to document the care plan failures. By then, she had spent the summer managing a broken ankle that existed in hospital records and on her leg, but nowhere in the facility's care documentation.
The violation affects how nursing homes must coordinate with hospitals and update care plans when residents return with new medical conditions. It also highlights the gap between facility policies and actual practice – Liberty Nursing Center had written procedures for medical device documentation but failed to follow them for a resident with an obvious orthopedic injury.
Federal records show this was the only care plan deficiency identified during the August inspection, suggesting the problem was specific to this resident rather than a systemic failure affecting multiple patients. However, the two-month duration of the oversight indicates a significant breakdown in the basic nursing home responsibility to maintain current, comprehensive care plans for all residents.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LIBERTY NURSING CENTER OF COLERAIN INC in CINCINNATI, OH was cited for violations during a health inspection on August 27, 2025.
She would remain at the facility until August 2, but inspectors found no evidence that staff ever developed a plan to care for her injury.
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.