The resident fell on December 7, 2025, at 9:20 PM. Staff immediately called the facility's nurse practitioner, who ordered a "STAT x-ray" of the right hip. In medical terms, STAT means immediately or right away.
The x-ray wasn't performed until 12:09 PM the following day.
The mobile x-ray provider's images revealed a right subcapital hip fracture and reduced bone mass. The radiologist noted the fracture was "of unknown chronicity," meaning it was unclear when the break occurred.
Federal inspectors reviewed the resident's medical record during a January 2 complaint investigation. The resident had previously been diagnosed with a right femur fracture and Alzheimer's disease, which gradually destroys memory, thinking, and reasoning skills.
When confronted about the delay, the facility's Director of Nursing admitted the error in an email to inspectors on December 31. "The x-ray was entered incorrectly," she wrote. "It was entered as one-time only instead of stat."
The mobile x-ray company told the facility that STAT requests should be completed within four hours. Instead, this resident waited nearly four times longer.
The nursing director's email revealed the facility has since changed its policy. "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."
Hip fractures in elderly residents, particularly those with Alzheimer's disease, require immediate medical attention. The resident's existing diagnosis of reduced bone mass made them particularly vulnerable to serious injury from falls.
The inspection report doesn't detail what happened to the resident during the 15-hour wait or their current condition. It also doesn't specify whether the facility provided pain management or other treatment while waiting for the diagnostic imaging.
Federal inspectors determined the facility failed to obtain diagnostic services promptly to meet residents' needs. The violation was classified as causing minimal harm or potential for actual harm.
This wasn't an isolated system failure. The facility's own contracted mobile provider had clear turnaround standards that weren't met, and staff had to be retrained on how to properly order urgent imaging studies.
The case highlights a broader challenge in nursing home care: ensuring residents receive timely medical services when facilities rely on outside contractors for diagnostic testing. The resident's Alzheimer's diagnosis meant they may not have been able to communicate their pain level or advocate for faster treatment.
Inners Creek operates at 100 West Queen Street in Dallastown, serving residents who require skilled nursing and rehabilitation services. The facility was cited for failing to provide timely diagnostic services under federal regulations governing nursing home operations.
The inspection was conducted in response to a complaint, though the report doesn't specify who filed the complaint or what initially triggered the investigation. Federal and state inspectors routinely investigate nursing homes following complaints from residents, families, or staff members.
The resident with the hip fracture remains at the facility, according to the inspection report, which noted this violation affected "few" residents during the review period.
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.