The incident occurred January 2nd when Licensed Vocational Nurse 1 found the resident at the edge of her bed with her right foot hitting the footboard. Rather than call for help as facility policy required, the nurse decided to move the patient by herself because "everyone was busy caring for other residents."
LVN 1 used a draw sheet to pull the resident toward the center of the bed while the patient's legs were crossed and straight. As the nurse turned the resident to her left side, the patient moved her legs and her right knee struck the exposed bed frame at the bottom of the bed.
The nurse immediately noticed the resident grimacing and moaning. Redness and swelling appeared on the patient's right knee.
An X-ray taken the next day at 12:01 p.m. revealed a fracture of the right distal femur. The resident was transferred to a hospital emergency room that afternoon.
Hospital records described "swelling and deformity of the right distal thigh" with an acute distal femur fracture. The patient was admitted for pain control, immobilization, and orthopedic evaluation. Doctors monitored for complications including bleeding, blood clots, and skin breakdown.
Two nursing assistants had noticed something wrong with the resident's right knee the evening before the X-ray. Certified Nursing Assistant 1 told investigators that she and CNA 2 saw the resident's "right knee was bending weirdly" during their 3 p.m. to 11 p.m. shift on January 2nd. They informed LVN 1, who repositioned the resident and "accidentally bumped the resident's right knee on bed frame."
The nursing assistants confirmed the resident required two-person assistance for all care.
An orthopedic surgeon who examined the patient concluded the injury was likely due to malunion — a previously broken bone that had healed in an abnormal position. Surgery was not recommended due to the patient's dementia and inability to walk.
The Director of Nursing acknowledged that LVN 1 should have called for help since the resident required two-person assistance.
Colonial Care Center's own policy on positioning and moving residents required staff to assess each patient's physical abilities, mobility limitations, strength, and awareness before moving them. The policy mandated that staff "use maximum precautions when moving or lifting residents" and "obtain assistance from other professionals as needed."
The facility's policy also required staff to evaluate a resident's joint and muscle limitations and ability to follow directions before any repositioning attempt.
The nurse's decision to work alone violated these requirements. Hospital records showed the mattress did not completely cover the bed frame, leaving the metal structure exposed where the patient's knee made contact.
The resident spent multiple days hospitalized for an injury that occurred during what should have been routine repositioning care. The orthopedic consultation report noted the patient was "stable for discharge from an orthopedic standpoint" after medical evaluation and treatment.
Federal inspectors classified the violation as causing actual harm to residents. The inspection was conducted in response to a complaint about the facility's care practices.
The incident illustrates how staffing pressures can lead nurses to cut corners on safety protocols designed to protect vulnerable residents. The patient's dementia meant she could not advocate for herself or request proper assistance during the repositioning that ultimately broke her leg.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Care Center from 2026-01-29 including all violations, facility responses, and corrective action plans.