Federal inspectors found that Inners Creek Skilled Nursing and Rehabilitation Center failed to obtain diagnostic services promptly for the resident, who fell on December 7, 2025, at the facility on West Queen Street.
According to the incident report, staff notified the Certified Registered Nurse Practitioner at 9:20 PM about the fall. The practitioner immediately ordered a "STAT x-ray" of the resident's right hip.
In medical terminology, STAT means immediately or right away.
The facility's contracted mobile x-ray provider didn't perform the imaging until 12:09 PM the following day — nearly 15 hours later. The x-ray revealed a right subcapital hip fracture and noted reduced bone mass. The radiologist couldn't determine how long the fracture had existed.
The resident's medical record showed a history of right femur fracture and Alzheimer's disease, a progressive brain condition that destroys memory, thinking and reasoning skills.
In an email to inspectors on December 31, 2025, the Director of Nursing acknowledged the delay resulted from an administrative error. "The x-ray was entered incorrectly," she wrote. "It was entered as one-time only instead of stat."
The nursing director explained that the x-ray company's standard turnaround time for STAT requests is four hours. She said the facility has since notified all providers that urgent x-rays requiring immediate results would require sending residents to the hospital instead of waiting for mobile services.
The inspection, completed January 2, 2026, found the facility violated federal requirements for providing timely diagnostic services. Inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
This represents one of two residents reviewed for falls during the inspection, though only one case involved delayed diagnostic services.
The facility contracts with an outside provider for mobile x-ray services rather than maintaining on-site imaging equipment. This arrangement requires coordination between nursing staff, medical practitioners and the external imaging company.
Federal regulations require nursing homes to provide necessary diagnostic services promptly or have agreements with approved providers to obtain them quickly. The 15-hour delay exceeded both the medical urgency implied by the STAT order and the contractor's stated four-hour turnaround time for emergency requests.
For a resident with Alzheimer's disease and a history of fractures, prompt imaging after a fall becomes particularly critical. The progressive nature of Alzheimer's can make it difficult for residents to communicate pain or describe their symptoms accurately, making objective diagnostic tests essential for proper care decisions.
The facility's acknowledgment that it would change protocols for future urgent imaging needs suggests recognition that the current system failed to meet medical standards for emergency diagnostic services.
The inspection found few residents affected by the diagnostic services deficiency, indicating this was not a widespread problem across the facility's operations.
However, for the resident who experienced the 15-hour delay, the consequences of the administrative error meant spending nearly a full day with an undiagnosed hip fracture while staff waited for imaging that should have been completed within four hours of the fall.
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.