George Ade Memorial: Missed Hip Fracture After Fall - IN
The resident fell sometime before October 26, 2025. That evening at 9:40 p.m., nurses documented severe pain in his right knee and neck, decreased strength and range of motion in the right leg, and swelling in the right knee and right foot. They gave him acetaminophen, elevated his leg, and called the physician. The next morning he couldn't stand from the toilet without two staff members helping him. His legs were hurting. The physician was notified again. No nursing assessment of the legs was documented.
The physician ordered a right knee x-ray on October 27. It came back negative for fractures on October 29. That same day, a physician's progress note acknowledged it was difficult to evaluate the resident because of his dementia, but recorded that he was still complaining of back, right leg, and right knee pain and still had trouble walking.
On October 30, a Medicare meeting report noted he needed moderate to maximum assistance from one to two staff members to walk, using a front-wheeled walker. Staff were providing gait training. He was being walked.
He had a broken hip the entire time.
On the morning of November 1, a nursing assistant noticed something that should have been caught days earlier. The resident's right leg looked shorter than his left. There was a bruise on his right hip, light yellow with a purple center, six centimeters by five centimeters. When touched, the leg caused him pain. It was rotated outward. A hip x-ray was finally ordered. It showed a right femoral neck fracture. He was transferred to the hospital that afternoon and underwent a hemiarthroplasty, a procedure in which the broken ball of the hip joint is replaced with an artificial implant. He was back at the facility by November 4.
The physical therapist who worked with the resident after the fall described the picture clearly during an interview with inspectors on November 12. Before the fall, the resident had been independent with walking. After it, he needed two staff to transfer him and some days would not bear any weight at all. His gait had a limp that wasn't normal for him. His pain varied day to day, which is consistent with a femoral neck fracture in an elderly person with dementia who cannot reliably communicate what hurts and where. The physical therapist noted a big discrepancy in his status after the fall.
The Director of Nursing told inspectors she had only asked for the right knee to be x-rayed because that was what the resident appeared to have hurt when he fell. She acknowledged that no further assessments of the right leg had been completed by nurses after the pain increased and his functional status worsened, not until November 1 when the nursing assistant noticed the visible signs of a hip injury.
Six days. During that time, nurses documented his pain repeatedly. They noted he couldn't stand without two people. They noted his gait was off. They provided gait training. Nobody connected the pattern to his hip.
A femoral neck fracture in an elderly person with dementia does not always present the way a fracture presents in a younger patient. The classic signs, a leg rotated outward and visibly shortened, can take days to become obvious, particularly when swelling and pain are attributed to a different injury. But that is precisely why a thorough assessment matters when a resident's functional status is changing and pain is not resolving. The knee x-ray came back clean on October 29. His pain and weakness continued. The clinical picture had not been explained. No one went looking further.
The inspection was conducted on November 12, 2025, following a complaint. The deficiency was cited at a level of minimal harm or potential for actual harm, a designation that reflects the regulatory floor for documentation failures, not a medical judgment about what the resident experienced during those six days.
He had surgery to replace part of his hip joint. He came back to the same facility four days later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for George Ade Memorial Health Care Center from 2025-11-12 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 22, 2026 · Our methodology
GEORGE ADE MEMORIAL HEALTH CARE CENTER in BROOK, IN was cited for violations during a health inspection on November 12, 2025.
The resident fell sometime before October 26, 2025.
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.