The resident, identified only as Resident 1 in federal inspection records, fell at Inners Creek Skilled Nursing and Rehabilitation Center on December 7, 2025, at 9:20 PM. Staff immediately contacted the facility's nurse practitioner, who ordered a STAT X-ray of the resident's right hip.
In medical terminology, STAT means immediately or right away.
The mobile X-ray company didn't perform the scan until 12:09 PM the following day — nearly 15 hours later. The X-ray revealed a right subcapital hip fracture and reduced bone mass. The radiologist noted the fracture was "of unknown chronicity," meaning they couldn't determine when it occurred.
Federal inspectors who reviewed the case found the facility failed to obtain diagnostic services promptly for residents who needed them.
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 experience severe memory loss, confusion, and difficulty with daily tasks, along with behavior changes that eventually prevent them from carrying out simple activities.
When inspectors questioned the delay, the facility's Director of Nursing admitted staff had made a critical error in December. "The x-ray was entered incorrectly," the director wrote in an email to inspectors on December 31, 2025. "It was entered as one-time only instead of stat."
The mobile X-ray company told facility administrators that their standard turnaround time for STAT requests is four hours — not 15.
The nursing director's email revealed the facility had quietly changed its policy following the incident. "We have notified all providers that in-house stat X-rays will not be done related to the turnaround time," the director wrote. "If it is necessary to obtain the X-ray stat, the resident will need to be sent to the hospital."
This policy change means future residents requiring immediate X-rays will face transport to a hospital emergency room rather than receiving the diagnostic service at the nursing home.
The inspection occurred January 2, 2026, following a complaint about the facility's care practices. Inspectors reviewed two residents who had experienced falls but found the delayed diagnostic service problem affected only Resident 1.
Hip fractures in elderly residents, particularly those with dementia, represent serious medical emergencies. The bones of older adults often become more fragile due to conditions like osteopenia, which reduces bone mass and increases fracture risk during falls.
For residents with Alzheimer's disease, the combination of cognitive impairment and physical injury creates additional complications. These patients may not be able to communicate their pain clearly or understand why they're experiencing discomfort, making prompt medical evaluation even more critical.
The facility's admission that staff incorrectly entered the X-ray order suggests a breakdown in the communication system between nursing staff and diagnostic service providers. The 15-hour delay meant the resident spent nearly two-thirds of a day with an undiagnosed hip fracture.
Federal regulations require nursing homes to ensure residents receive necessary diagnostic services promptly. The facility's contracted mobile X-ray provider had the capability to respond within four hours for urgent requests, but staff failed to use the proper ordering protocol.
The inspection classified this violation as causing "minimal harm or potential for actual harm" to residents. However, the case demonstrates how administrative errors can significantly delay medical care for vulnerable nursing home residents who depend on staff to advocate for their immediate health needs.
Resident 1's case illustrates the cascading effects of a single documentation mistake in nursing home care, where a checkbox error extended a resident's suffering for hours while a hip fracture went undiagnosed.
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.