**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility reported investigation, review of facility policy, stand lift Operator's Instructions, resident interview, and staff interview, the facility failed to provide appropriate safety/supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) who sustained a major injury during an EZ stand lift (mechanical sit-to-stand lift). Failure to follow the facility policy for EZ stand transfers and safety interventions resulted in a fracture of Resident #1's left arm. Findings include: Review of the facility policy titled, EZ Stand Lift occurred on 11/29/23. This policy, revised 02/13/18, stated, . Purpose: To lift and transfer resident/patient safely with as little physical effort as possible. Position the EZ stand in front of the resident/patient. Have the resident/patient place his feet (or help as needed) on platform and position his shins into the shin forms. Place leg strap around legs, buckle, and pull the strap to tighten. The EZ Way Smart Stand Operator's Instructions, page 6, stated, . Use of Shin Pad Strap: If a caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the shin strap around the patient's legs. Review of Resident #1's medical record occurred on 11/29/23. Diagnoses included paralytic syndrome (weakness/paralysis) following cerebral infarction (stroke) affecting left non-dominant side and contractures of the left hand and left shoulder muscle. A quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The care plan at the time of the incident indicated EZ stand transfers with one assist. The facility reported a fall incident to the state agency on 11/22/23 and immediately started an investigation. The facility's final investigation report stated, on 11/22/23 at 9:00 a.m., . Resident was being transferred via E-Z stand lift. While transferring, resident's knees gave out and went to the side and her arms 'chicken winged' and started to slide out of the lift. A chair placed under the resident and she was assisted via Hoyer lift. Resident later complained of pain to the left shoulder. She was taken to the emergency department and diagnosed with a closed displaced fracture of the left humerus bone received. Resident to not be lifted all the way up in the lift . may have been lifted too high in the lift which caused her left arm to slip out. During an interview on 11/29/23 at 2:58 p.m., when asked about the events that occurred on 11/22/23, Resident #1 confirmed two staff were present during the EZ stand lift transfer, and stated, They [the CNAs] didn't have my feet on the platform properly before they started to stand me up. When asked if staff used the leg straps during the transfer, she stated no and further stated they never do. During an interview on 11/29/23 at 4:11 p.m., the CNA (#1) stated Resident #1's legs went to the side (indicating to the left) as they began to lift the resident. When asked if she used the leg straps during Resident #1's transfer on 11/22/23, the CNA (#1) stated, No. During an interview on 11/29/23 at 4:34 p.m., two physical therapy staff members (#4 and #5) stated they would expect staff to use the EZ stand as ordered and use the leg straps per facility policy. The facility staff failed to strap Resident #1's legs into the EZ stand lift and ensure the resident was not lifted too high during a transfer which resulted in a fracture.