Liberty Nursing Center of Colerain: Care Plan Failures - OH
The resident, identified in inspection records only as Resident 80, had lived at the Livingston Road facility since December 2022. She carried serious diagnoses: end-stage renal disease, type two diabetes, and chronic obstructive pulmonary disease. On June 6, 2025, she was hospitalized. An x-ray taken during that stay showed a fracture to her left ankle. Orthopedic specialists evaluated her, fitted her with a splint on her left lower extremity, and scheduled a follow-up appointment for June 10.
She was discharged back to Liberty Nursing Center on June 8.
From that point forward, inspectors found no physician orders in her medical record for care of the left foot. No orders for care of the splint. And no care plan, the document that guides how nursing staff approach a resident's daily needs, that mentioned the fracture, the splint, or what should be done about either.
This continued until August 2, 2025, when she was discharged from the facility.
The gap lasted nearly two months. A cognitively intact woman, one who according to a July assessment needed help with mobility and toileting, was moving through a nursing home with a broken ankle and a splinted leg while the paperwork governing her care said nothing about it.
When inspectors sat down with the facility's Assistant Director of Nursing on August 19, the ADON confirmed what the records already showed: Resident 80 had a splint on her left lower extremity when she came back from the hospital, and there were no orders or care plan entries reflecting its presence or the care it required. A registered nurse, interviewed separately on August 25, said the same thing. The care plan did not reflect the fracture. It did not reflect the splint. It did not reflect care for either.
The facility's own policy on medical devices, dated January 2018, states that the use of medical devices should appear on the care plan, and that if a device is not to be removed, orders should say so.
Neither condition was met.
The deficiency was tagged at a level of minimal harm or potential for actual harm and affected one of eleven residents whose care plans inspectors reviewed. The facility census at the time was 67 residents. The inspection was conducted as a complaint investigation.
What the inspection does not answer is what happened during those two months at the level of daily care. A splint on a lower extremity requires monitoring. Skin underneath a splint can break down. Positioning matters. Whether any of that monitoring happened informally, outside the written record, is not something inspectors documented. What they documented is that no one wrote it down, no one ordered it, and no one updated the plan that nursing staff rely on to know what a resident needs.
Resident 80 was discharged on August 2, three weeks before inspectors arrived. She was gone before anyone with a clipboard confirmed that her fracture had never made it into her chart as something the facility was actively managing.
The inspection was completed August 27, 2025.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
LIBERTY NURSING CENTER OF COLERAIN INC in CINCINNATI, OH was cited for violations during a health inspection on August 27, 2025.
The resident, identified in inspection records only as Resident 80, had lived at the Livingston Road facility since December 2022.
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.