Colonial Care Center: Accident Hazards, Harm - CA
The licensed vocational nurse, identified in inspection records as LVN 1, told investigators she found the resident, a woman referred to as Resident 1, at the edge of her bed around 9:30 p.m. with her right foot pressing against the footboard. She knew the resident was a two-person assist. She decided to move her alone anyway.
"Everyone was busy caring for other residents," LVN 1 told the inspector.
She used a draw sheet to pull the resident up the bed. Both of the resident's legs were straight, with her right leg crossed over her left. As LVN 1 began turning her toward the left side of the bed, the resident moved her legs. Her right knee struck the bed frame, which was exposed because the mattress did not fully cover it.
The resident began grimacing and moaning. LVN 1 observed redness and swelling on the right knee.
The following day, January 3, Resident 1 was taken to the emergency room. An X-ray showed an acute distal femur fracture, a break at the lower end of the thigh bone, just above the knee. She was admitted for pain control, immobilization, and orthopedic evaluation, with monitoring ordered for bleeding, blood clots, and skin breakdown.
An orthopedic specialist examined her on January 5 and determined the fracture was likely due to malunion, meaning a prior broken bone had healed in an abnormal, misaligned position. Surgery was not recommended because of her dementia and because she was not ambulatory. The orthopedic report noted she was stable for discharge.
Two certified nursing assistants, CNA 1 and CNA 2, had been caring for Resident 1 earlier that same evening shift. CNA 1 told inspectors that at some point during the shift, she and CNA 2 noticed the resident's right knee bending abnormally. They reported it to LVN 1. That report, in CNA 1's account, was what led to LVN 1 going to reposition the resident.
CNA 1 confirmed that Resident 1 required a two-person assist for care.
The facility's own policy on positioning and moving residents, though undated, stated that staff must assess a resident's physical abilities and mobility limitations before any movement, use maximum precautions, and obtain assistance from other staff as needed.
The Director of Nursing, interviewed by inspectors on January 29, said LVN 1 should have called for help.
That was the extent of it. No explanation of why the bed frame was exposed. No account of what happened between the time LVN 1 noticed the swelling and the time Resident 1 reached the emergency room. The inspection record does not say whether anyone documented the injury that night, or when the decision was made to send her out.
Resident 1 had dementia and could not reposition herself. She was dependent on the staff around her to follow the most basic precautions. On the night of January 2, one nurse made a unilateral decision that everyone being busy was reason enough to move a fragile, cognitively impaired woman alone, with her legs tangled, toward a bed frame that jutted out past the edge of the mattress.
The federal inspection, conducted as a complaint investigation, cited the violation as causing actual harm to one of a small number of residents affected. The agency's findings were recorded on January 29, 2026.
Resident 1 was discharged from the hospital back to Colonial Care Center. The inspection record does not say whether she was in pain when she returned.
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.
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: August 9, 2026 · Our methodology
COLONIAL CARE CENTER in LONG BEACH, CA was cited for violations during a health inspection on January 29, 2026.
with her right foot pressing against the footboard.
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.