The resident at Grand Islander Center sustained "significant, non-operable fractures to the left tibia and fibula" during what federal inspectors determined was an improper transfer on September 1, 2025.
Staff A, the nursing assistant involved, told inspectors he was helping the resident transfer in the bathroom when "the resident pulled up to the bar from his/her wheelchair." As he assisted the resident to stand, "s/he suddenly went backwards into the wheelchair."
The resident told the nursing assistant they were "unable to get out of the wheelchair" after the fall. Staff A then repositioned the resident and called for help from another worker to move the person to bed.
But the resident's care plan and transfer evaluation both clearly stated that two staff members must assist with every transfer, using a gait belt. The Director of Rehabilitation confirmed to inspectors that the type of fractures the resident sustained "are consistent with twisting during a SPT when the leg is not properly advanced."
SPT refers to a stand-pivot transfer, a common nursing home procedure for moving residents from wheelchairs to beds or other surfaces.
Multiple interviews revealed this wasn't an isolated incident. Both residents and staff reported other occasions when the same resident "twisted or fell backward during transfers," according to the inspection report.
Staffing records showed both nursing assistants involved were on duty during the timeframe when the injury occurred. Staff A worked back-to-back shifts from 5 p.m. on August 31 through 7 a.m. on September 2, covering 38 hours over three days. Staff B worked three consecutive day and evening shifts during the same period.
When inspectors interviewed the facility administrator on November 25, she could not provide evidence that the resident received the two-person assistance required by the care plan during transfers.
The injury occurred just weeks after Grand Islander Center received another citation for a similar transfer-related incident during an October complaint investigation.
Federal inspectors concluded the facility "did not ensure that the resident received adequate supervision and assistance to prevent accidents, which likely contributed to the injuries sustained."
The timing was particularly problematic. The Director of Nursing told inspectors that after the October citation, the facility had already begun implementing new safety measures. Staff education on "safe resident handling and fall prevention" was completed on November 20, just five days before the current inspection.
The facility also initiated a comprehensive review on November 20 "to identify residents who may be at risk related to supervision and use of assistive devices." All residents were supposed to have accurate transfer status documentation and appropriate equipment.
Additional corrective measures included rehabilitation staff education on "timely communication and documentation of resident transfer updates" that began November 1. Care plan training started November 6.
Grand Islander Center also implemented random gait belt audits for four weeks, followed by monthly checks for three months. Weekly fall audits began October 14 and will continue for four weeks, then monthly for three months.
The facility scheduled weekly reviews of residents with condition changes for four weeks, then monthly for two months. All audit findings will be reviewed during Quality Assurance and Performance Improvement meetings.
Despite these interventions, the resident with the leg fractures represents what inspectors classified as "actual harm" to "few" residents.
The non-operable fractures mean the resident's broken tibia and fibula bones cannot be surgically repaired. The person must heal naturally from injuries that federal inspectors determined resulted from inadequate assistance during a routine bathroom transfer that should have involved two staff members with proper safety equipment.
The facility's compliance date for all corrective measures was November 20, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grand Islander Center from 2025-11-25 including all violations, facility responses, and corrective action plans.