The December 7 incident at Inners Creek Skilled Nursing and Rehabilitation Center revealed a breakdown in the facility's diagnostic services that left a vulnerable resident in pain with an undiagnosed fracture overnight.
Staff found the resident after the fall at 9:20 PM and immediately contacted the facility's nurse practitioner, who ordered a "STAT" X-ray of the right hip. In medical terminology, STAT means immediately or right away.
The mobile X-ray company didn't arrive until 12:09 PM the following day.
The delayed imaging revealed a right subcapital hip fracture with osteopenia, a condition of reduced bone mass that makes bones more fragile. The radiologist noted the fracture was "of unknown chronicity," meaning they couldn't determine when it occurred.
The resident's medical history included a previous right femur fracture and Alzheimer's disease, a progressive brain condition that destroys memory and reasoning skills. People with Alzheimer's often cannot communicate pain effectively or understand what happened to them after an injury.
When federal inspectors questioned the delay, the Director of Nursing admitted the facility had made an error. In an email dated December 31, the nursing director wrote: "The x-ray was entered incorrectly. It was entered as one-time only instead of stat."
The facility's contracted mobile X-ray provider maintains a four-hour turnaround time for emergency requests. But the resident waited nearly four times longer than that standard.
The nursing director's email revealed the facility had essentially given up on providing timely emergency imaging. "We have notified all providers that in-house stat X-rays will not be done related to the turnaround time," she wrote. "If it is necessary to obtain the X-ray stat, the resident will need to be sent to the hospital."
This policy shift means future residents requiring emergency imaging would face transport to a hospital emergency room rather than receiving diagnostic services at the nursing home where they live.
Federal inspectors cited the facility for failing to provide timely diagnostic services, noting that residents have the right to receive necessary medical care promptly. The violation carries a designation of "minimal harm or potential for actual harm."
Hip fractures in elderly residents represent serious medical emergencies. The injuries often require immediate surgical intervention, and delays in diagnosis can lead to complications including increased pain, displacement of bone fragments, and prolonged recovery times.
For residents with dementia like Alzheimer's disease, diagnostic delays create additional challenges. These patients may not remember falling or understand why they're experiencing pain, making clinical assessment more difficult without imaging confirmation.
The facility's admission that it incorrectly entered the X-ray order suggests systemic problems with emergency protocols. Staff training on proper ordering procedures and communication with diagnostic services appears inadequate.
The December incident occurred during a complaint investigation, meaning someone had already raised concerns about care quality at the facility before inspectors arrived.
The 15-hour delay meant the resident spent an entire night with an undiagnosed hip fracture. During those hours, staff likely moved and repositioned the resident for routine care, potentially causing additional pain and complications.
The facility's decision to abandon in-house emergency imaging represents a significant reduction in services for its residents. Future medical emergencies requiring immediate diagnostic confirmation will now require ambulance transport, emergency room evaluation, and potential overnight hospital stays.
The resident with the fractured hip faced all of these consequences because someone clicked the wrong box on a computer screen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inners Creek Skilled Nursing and Rehabilitation Ce from 2026-01-02 including all violations, facility responses, and corrective action plans.