Brookside Rehab: Delayed Fracture Treatment After X-Ray - VA
The resident, identified in inspection records only as R8, had been X-rayed on November 19, 2024, after staff discovered a bruise that could not be explained. The X-ray company's practice was to call the facility if results showed a broken bone or fracture. No call came. No nurse called them back. The results sat unretrieved.
The delay was not discovered until federal inspectors arrived nearly a year later, on October 21, 2025.
When inspectors sat down with LPN #1 that afternoon and walked her through the facility's own protocol for unexplained injuries, she described it without hesitation: notify the director of nursing, the nurse practitioner, and the resident's responsible party; assess for pain; conduct a head-to-toe exam; schedule an X-ray if ordered. She said the X-ray company calls the facility when results show a fracture.
Then inspectors asked what a nurse should do if that call never comes.
"The nurse should call the X-ray company for the results," LPN #1 said.
Then they showed her R8's nurse's notes alongside the X-ray report. She reviewed them. She agreed that no one had made that call. "The nurse should have called the X-ray company for the result," she told inspectors. She agreed there had been a delay in treatment for R8.
RN #5 was interviewed separately, about forty minutes later. Inspectors asked if she remembered receiving a call from the X-ray company on November 19, 2024, with R8's results. She said she did not recall receiving one. After reviewing the same records, she reached the same conclusion LPN #1 had. The X-ray company should have been called. It was a delay in treatment.
Two nurses, the same account, the same admission.
The inspection report references a femoral neck fracture, a type of broken hip involving the femur and pelvis, among the most serious injuries a nursing home resident can sustain. Hip fractures in elderly patients carry significant risk of complications, immobility, and deterioration. The report also references dementia, which affects memory, thinking, language, judgment, and behavior, among the conditions relevant to R8's care.
What the report does not say is how long R8 went without treatment, what pain R8 experienced during that time, or what the consequences of the delay turned out to be. CMS rated the violation at the level of minimal harm or potential for actual harm, affecting few residents. That rating reflects the agency's classification, not a clinical determination about what R8 endured in the days after that X-ray was taken and the phone was never picked up.
At 3:05 in the afternoon on October 21, inspectors gathered the facility's leadership and told them what they had found. Present were the administrator, the director of nursing, a regional director of clinical operations, and a risk nurse. The inspection report notes that no further information was provided before inspectors left the building.
The protocol existed. The nurses knew it. Both of them said so, out loud, to federal inspectors, after looking at the records. One phone call to the X-ray company on the evening of November 19, 2024, would have retrieved R8's results that same day. Nobody made it.
R8 had a broken hip. Nobody knew. Days passed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookside Rehab & Nursing Center from 2025-10-21 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 24, 2026 · Our methodology
BROOKSIDE REHAB & NURSING CENTER in WARRENTON, VA was cited for violations during a health inspection on October 21, 2025.
The resident, identified in inspection records only as R8, had been X-rayed on November 19, 2024, after staff discovered a bruise that could not be explained.
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.