Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Nursing Center Of Colerain Inc during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including COPD, CKD, Alzheimer’s disease, and GERD, reported abdominal pain and chocolate-colored emesis, after which a physician ordered monitoring and a clear liquid diet for two days. Documentation showed only one follow-up note stating there was no further emesis that shift, with no subsequent monitoring notes entered for nearly two days, and no corresponding orders for monitoring or a clear liquid diet entered into the record. The resident later complained of chest and abdominal pain and was sent to the ED, and the DON confirmed that required orders and documentation of monitoring were missing, contrary to the facility’s charting and documentation policy.
A resident with severe cognitive impairment and multiple medical conditions, including infection and type II DM, had physician orders for Seroquel via J-tube three times daily and ciprofloxacin via J-tube every 12 hours. Audit review showed that the 9:00 A.M. doses of both medications were repeatedly administered several hours late over multiple days, outside the facility’s stated one-hour-before/after administration window, as confirmed by the DON. Resident Council minutes also reflected complaints about late medications, and facility policy required immediate documentation after medication administration.
The facility did not have a dedicated, full-time DON after the DON went on medical leave, instead assigning the only MDS nurse to serve as acting DON while continuing her MDS duties. This resulted in the absence of a full-time DON as required, potentially impacting all residents.
A resident's private health information, including diagnoses and prescribed medications, was disclosed by facility staff in a written response to the Better Business Bureau, a non-governmental organization, following a complaint from the resident's family. The information was sent despite facility policy requiring confidentiality of medical records and limiting access to authorized staff and business associates.
A resident with multiple chronic conditions and a recent left ankle fracture returned from the hospital with a splint, but the facility failed to update the care plan or obtain physician orders for splint and fracture care. Staff confirmed the absence of documentation and care planning for the injury and device, contrary to facility policy.
A resident with moderate cognitive impairment and an open abdominal wound, who required staff assistance for bathing, received only four documented baths or showers during a period when at least 15 were scheduled. The ADON confirmed that the facility's expectation was for dependent residents to be offered at least two baths or showers per week, but this was not met.
Two residents did not receive appropriate care as physician orders for fracture and splint management, as well as wound care, were not implemented. One resident returned from the hospital with a splint for a left ankle fracture, but no orders or care plans were documented for its care. Another resident's wound care orders for a right lower leg ulcer were not followed, and updated wound clinic instructions were delayed by two days before being implemented. Staff confirmed these omissions and delays.
Two residents with cognitive impairment and significant medical histories experienced falls that were not investigated in a timely manner, with one fall investigation delayed and another not completed at all. The facility's policy required prompt identification of fall causes, but this was not followed, as confirmed by the ADON and an LPN.
The facility failed to adhere to professional standards for food labeling and storage, as observed in the kitchen's walk-in refrigerator and freezer. Undated items included various food products, and expired milk was found. Opened boxes of beef and veal patties were not properly secured or dated. Dietary staff confirmed these findings, which violated the facility's policies on refrigerated storage and date marking.
A facility failed to update a resident's medical records to reflect a change in their advance directives. The resident, with multiple health conditions, was initially recorded as a full code, but a DNR form indicated a change to DNR Comfort Care - Arrest. The ADON stated that the hospice provider uploaded the DNR form, but the facility was unaware of the change, contrary to the facility's policy requiring prominent display of advance directives in medical records.
A facility failed to routinely monitor the dialysis access site for a resident with ESRD who required hemodialysis. Despite the care plan's directive to check and change the dressing daily, there was no documentation of such monitoring, and no current physician orders for routine monitoring were found. This deficiency was confirmed through a review of the resident's medical record and an interview with the ADON.
A facility failed to ensure proper disposal of an insulin needle, resulting in a staff member being injured. An STNA was stuck by a needle while emptying a trash can in a resident's bathroom. The facility could not determine who disposed of the needle or which resident it was used on, as the resident did not have orders for insulin. This incident revealed a lapse in adherence to the infection control policy, which requires sharps to be disposed of in designated containers.
Failure to Monitor Resident and Implement Ordered Clear Liquid Diet After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to monitor and evaluate a resident after a documented change in condition and to implement physician-ordered interventions. Resident #2, who had COPD, stage 3 chronic kidney disease, Alzheimer’s disease, GERD, and unspecified abdominal pain, was moderately cognitively impaired but did not exhibit behaviors or reject care. On 02/12/2026 at 10:40 A.M., the resident complained of abdominal pain and had chocolate-colored emesis. The physician was notified and ordered monitoring and a clear liquid diet for two days, as documented in the progress note. Later that day at 6:53 P.M., a progress note indicated there was no further emesis noted during that shift. After the 6:53 P.M. note on 02/12/2026, there were no further progress notes or documented monitoring of the resident until 02/14/2026 at 12:30 P.M., when the resident again complained of chest pain and abdominal pain and was sent to the emergency department for further evaluation. No physician orders for monitoring or a clear liquid diet were entered into the medical record, despite the earlier documented physician instructions. The DON confirmed that orders should have been entered for monitoring and a clear liquid diet and verified the absence of progress notes documenting monitoring during this period. Facility policy on charting and documentation required that all services provided and any changes in the resident’s condition be documented in the medical record, which did not occur in this case.
Failure to Administer Medications in a Safe and Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in a safe and timely manner for one resident. The resident was admitted for aftercare following explantation of a hip joint prosthesis and had diagnoses including infection and inflammatory reaction due to orthopedic prosthetic devices, acute embolism and thrombosis of deep veins, type II diabetes mellitus, and lumbosacral radiculopathy. The most recent MDS assessment documented that the resident was severely cognitively impaired, rarely or never understood, had no behaviors, and did not reject care. Physician orders included Seroquel (quetiapine fumarate) 12.5 mg via J-tube three times daily for bipolar disorder and ciprofloxacin 750 mg via J-tube every 12 hours for infection. Review of the medication administration audit report showed that on three consecutive days, the 9:00 A.M. doses of Seroquel and ciprofloxacin were administered several hours late: at 12:59 P.M., 12:17 P.M., and 12:32 P.M., respectively. In interview, the DON stated that nurses are expected to administer medications within one hour before or one hour after the scheduled time and confirmed that these medications were given outside the facility’s parameters for safe medication administration. Resident Council minutes from February and March documented resident complaints about medications being administered late. The facility’s policy on documentation of medication administration required that administration be documented immediately after it is given.
Lack of Dedicated Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a dedicated Registered Nurse (RN) to serve as the full-time Director of Nursing (DON), as required. The DON had been on medical leave and absent from the facility since 07/22/25. In response, the facility assigned the only MDS nurse, RN #300, to act as the interim DON while she continued to perform her full-time MDS duties. Interviews with the Administrator, Social Services Director, and Assistant Director of Nursing confirmed that RN #300 was the sole MDS nurse and was responsible for both the MDS and DON roles during this period. Review of the DON job description indicated that the DON is responsible for planning, organizing, developing, and directing the day-to-day functions of the nursing department and ensuring compliance with relevant regulations. The dual assignment of RN #300 to both the MDS and acting DON roles meant that the facility did not have a dedicated, full-time DON as required, potentially affecting all 67 residents in the facility.
Failure to Safeguard Resident Health Information in External Communication
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's private health information. Specifically, a written communication from the facility to the Better Business Bureau (BBB), a private non-governmental organization, included the resident's name, diagnoses, weights, prescribed medications, and other confidential information. This action was taken in response to a complaint made by the resident's family to the BBB. The facility's administrator confirmed that the response, which contained private health information, was sent to the BBB after consulting with the corporate office. The resident involved had an admission date of 04/29/21 and a discharge date of 05/14/25, with medical diagnoses including end stage renal disease, type two diabetes mellitus, and congestive heart failure. The Minimum Data Set (MDS) assessment indicated the resident had moderately impaired cognition and required supervision with activities of daily living. The facility's policy on confidentiality, dated October 2017, stated that personal and medical records would be safeguarded and access would be limited to authorized staff and business associates. Despite this policy, the facility disclosed confidential information to an unauthorized external entity.
Failure to Develop Comprehensive Care Plan for Resident with Ankle Fracture and Splint
Penalty
Summary
A deficiency was identified when the facility failed to develop an individualized, comprehensive care plan for a resident with multiple complex medical conditions, including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease. The resident was admitted with these diagnoses and later sustained a left ankle fracture, which was splinted during a hospital stay. Upon return to the facility, there were no physician orders for care of the left foot or splint, and the resident's care plan did not address the new fracture, the presence of the splint, or the required care for the affected limb. Interviews with facility staff, including the Assistant Director of Nursing and a Registered Nurse, confirmed that the care plan and medical record lacked documentation regarding the left ankle fracture and splint care. Review of facility policy indicated that the use of medical devices, such as splints, should be reflected in the care plan and corresponding orders. This omission was found during a review of 11 residents' care plans, affecting one resident, and was substantiated by medical record review, staff interviews, and policy review.
Failure to Provide Scheduled Bathing Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide appropriate bathing assistance to a resident who was dependent on staff for activities of daily living, including bathing. The resident, who had moderate cognitive impairment and an open abdominal wound, was care planned to receive staff assistance with bathing or showers per schedule and to be offered sponge baths if a full bath or shower could not be tolerated. Medical record review showed that, over a period when the resident should have received at least 15 baths or showers, only four were documented. This was confirmed by the Assistant Director of Nursing, who acknowledged that the expectation was for residents to be offered at least two baths or showers per week as scheduled.
Failure to Implement Physician Orders for Fracture and Wound Care
Penalty
Summary
The facility failed to implement physician orders and provide appropriate care for two residents with specific medical needs. For one resident with end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease, there was no documentation of orders or care plans for a left ankle fracture and splint following a hospital stay, despite the resident returning with a splint in place. Staff interviews confirmed the absence of orders and care plans related to the splint and fracture care during the resident's stay. Another resident with end-stage renal disease, cerebral infarction, and type two diabetes mellitus returned from the hospital with instructions for wound care to a right lower leg ulcer, specifically a wet-to-dry dressing change every eight hours. The facility did not implement these orders, and there was no documentation of physician contact for clarification. Updated wound care orders from a wound clinic were also not implemented until two days after they were received. Staff interviews confirmed the delay and lack of implementation of both the hospital and wound clinic orders for wound care.
Failure to Timely Investigate Resident Falls
Penalty
Summary
The facility failed to ensure timely investigation of resident falls, as evidenced by the lack of documented fall investigations for two residents. One resident with diagnoses including convulsions, dementia, and bipolar disorder experienced an unwitnessed fall and was found on the floor next to the bed, unable to describe the incident, and was subsequently sent to the hospital. The medical record for this resident did not contain any documentation of a fall investigation or interdisciplinary team (IDT) review for the incident, which was confirmed by the Assistant Director of Nursing (ADON). Another resident, with a history of end-stage renal disease, cerebral infarction, and type 2 diabetes mellitus, was identified as being at moderate risk for falls and had moderately impaired cognition. This resident experienced two falls: one while attempting to go to the restroom and another while waiting for transportation, the latter resulting in a laceration and scalp injury requiring hospital transfer. The facility delayed the investigation of the first fall and failed to complete an investigation for the second fall, as confirmed by an LPN. Facility policy required that possible causes of falls be identified within 24 hours, but this was not followed in these cases.
Improper Food Labeling and Storage in Facility Kitchen
Penalty
Summary
The facility failed to properly label and store food items in accordance with professional standards, as observed during a survey of the kitchen's walk-in refrigerator and freezer. Undated items included half of a ham in a plastic zip lock bag, shredded lettuce, tomato soup, shredded cheese, a carton of slaw, and green bell peppers. Additionally, a gallon of milk was found with an expired date. In the walk-in freezer, a box of beef patty fritters and a box of veal patties were opened, with the plastic bags not properly secured or dated. Dietary Staff #48 confirmed these findings during interviews. The facility's policies on refrigerated storage and date marking require that all refrigerated items be labeled with the product name and date of receipt, use, or opening, and that all food be used or discarded by the manufacturer's use-by date. These policies were not adhered to, leading to the deficiency.
Failure to Update Resident's Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that the medical records of a resident were updated to reflect a change in their advance directives. The resident, who had multiple diagnoses including quadriplegia, cerebral infarction, and congestive heart failure, was initially documented as a full code in the electronic medical record. However, a completed Do Not Resuscitate (DNR) form indicated a change to DNR Comfort Care - Arrest (DNR-CCA). The Assistant Director of Nursing (ADON) revealed that the hospice provider uploaded the DNR form into the resident's medical record, but the facility was unaware of this change. The facility's policy required that information about advance directives be prominently displayed in the medical record, which was not adhered to in this case.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to routinely monitor the dialysis access site for a resident with end stage renal disease (ESRD) who required hemodialysis. The resident, who had moderately impaired cognition and was dependent on staff for various activities of daily living, had a care plan that included interventions such as checking and changing the dressing at the access site daily and documenting it. However, a review of the resident's medical record and an interview with the Assistant Director of Nursing revealed that there was no documentation of routine monitoring of the dialysis access site. Additionally, there were no current physician orders for routine monitoring of the dialysis site, which contributed to the deficiency identified by the surveyors.
Improper Disposal of Insulin Needle Leads to Staff Injury
Penalty
Summary
The facility failed to ensure proper disposal of an insulin needle, which led to a staff member being injured. A State tested Nursing Assistant (STNA) was stuck by a hypodermic insulin needle while emptying the trash can in a resident's bathroom. The facility was unable to determine who disposed of the needle or which resident it was used on, as the resident in question did not have orders for insulin or injections. This incident highlighted a lapse in adherence to the facility's infection control policy, which mandates that sharps should not be thrown in the trash and must be disposed of in designated sharps containers. The Director of Nursing (DON) confirmed that the needle found in the trash did not belong to the resident of the room where it was discovered. The facility's infection control policy, which was undated, clearly stated that sharps should not be capped and must be placed in sharps containers. The incident report and subsequent interviews revealed that the facility could not identify the individual responsible for the improper disposal, indicating a breakdown in the facility's infection control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Home At Taylor's Pointe | 2.1 mi | ★★★★★ | 0 | 0 |
| Lakeridge Villa Health Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Mt Airy Gardens Rehabilitation And Nursing Center | 3.1 mi | ★★★★★ | 2 | 0 |
| Covenant Village Care Center | 3.3 mi | ★★★★★ | 6 | 0 |
| Burlington House Rehab & Alzheimer's Care Center | 3.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.