The incident at Grand Islander Center occurred during what inspectors called a "stand pivot transfer" — helping someone move from a wheelchair to another position. Staff A told investigators on November 25 that when assisting the resident to rise from the wheelchair, "s/he suddenly went backwards into the wheelchair." The resident told the aide they were unable to get out of the chair.
Multiple interviews revealed staff routinely ignored the resident's transfer requirements. Both the resident and nursing assistants reported previous incidents where the person "twisted or fell backward during transfers," according to the inspection report.
The resident's care plan and lift transfer evaluation clearly mandated assistance from two staff members using a gait belt. Instead, Staff A performed the transfer alone.
Federal investigators determined the fractures were "consistent with improper or inadequate assistance" during the transfer. The facility's Director of Rehabilitation confirmed that the type of leg injuries sustained matched what happens "when the leg is not properly advanced" during a twisting motion in a stand pivot transfer.
Staff schedules confirmed both Staff A and Staff B were on duty during the timeframe when the injury occurred. Staff A worked back-to-back shifts on August 31 and September 1, pulling 16-hour days that included 5 PM to 7 AM coverage. Staff B worked consecutive day and evening shifts during the same period.
Despite having adequate staffing, administrators could not provide evidence that the resident received proper two-person assistance as required.
The violation represents the second similar citation at Grand Islander Center in recent weeks. Inspectors had previously identified a comparable transfer safety failure during a complaint investigation on October 23-24.
After the earlier citation, facility leadership implemented multiple corrective measures. The Director of Nursing told investigators on November 21 that interventions began immediately, with most completed by November 20.
The facility conducted a comprehensive review of all residents to verify accurate transfer assessments and appropriate assistive devices. Direct care staff received mandatory education on safe resident handling and fall prevention.
The rehabilitation department initiated training on timely communication about resident transfer changes, starting November 1. Additional education on care plan processes and assessment updates began November 6.
Grand Islander Center also established ongoing monitoring systems. Random gait belt audits will occur weekly for four weeks, then monthly for three months, with findings reported to the facility's Quality Assurance and Performance Improvement committee.
Weekly fall audits started October 14 and will continue under the same schedule. The facility will also conduct weekly reviews of residents with condition changes for four weeks, followed by monthly reviews for two months.
Staff A attempted to manage the situation after the resident fell backward, repositioning them in the wheelchair before seeking help from Staff B to transfer the person to bed for care. However, the damage was already done.
The resident required hospitalization for the fractures, which inspectors classified as non-operable, meaning surgical repair was not possible or advisable. The injuries occurred to the left tibia and fibula — the two bones in the lower leg.
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 violation affected few residents but caused actual harm, according to the inspection classification. The incident occurred before the resident's hospitalization, though the exact date was not specified in inspection documents.
Despite the facility's extensive corrective action plan, the resident's leg bones remain broken, a permanent consequence of a transfer that should have involved two people but was performed by one.
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.