**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a pre-cancerous lesion to the right temple, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/8/2025 alleges that the resident was transferred to an acute care hospital from the facility to be evaluated for a chronic malignant (cancerous) wound on his/her right scalp which was found to have maggots (worm-like creatures that feed on decaying organic matter) in it. Additionally, the report indicated that the resident receives daily wound care to the wound, however, s/he does not allow the staff to clean it.Record review revealed the resident was admitted to the facility in September of 2022 with a diagnosis, including but not limited to, dementia.Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 0 out of 15, indicating severe cognitive impairment. Record review of a document titled Continuity of care consultation and referral form dated 12/13/2024 revealed that the resident had a dermatology appointment where a total of 11 pre-cancerous lesions were found on his/her scalp including the right temple. Additionally, the consultation form revealed that a follow-up was scheduled to recheck the lesion on the right temple in a month. Record review of a Continuity of care consultation and referral form dated 1/27/2025 revealed that the resident had a follow-up dermatology appointment where s/he was evaluated for a pre-cancerous lesion on his/her right temple. Additionally, the consultation form revealed an order for Aquaphor (an ointment) to be applied to the lesion twice daily for 14 days.Record review of the January and February 2025 Medication Administration Records revealed the Aquaphor was applied as ordered for the 14 days. Record review of an undated facility policy titled Skin Integrity Management states in part . Skin checks are completed and documented by a nurse weekly. Any wound identified is fully assessed, documented in the EMR [Electronic Medical Record] and a treatment order is obtained by the NP [Nurse Practitioner], MD [Medical Doctor] if warranted .Record review of the nursing notes revealed the following:2/6/2025- the dermatology office called the facility and indicated that the resident required a MOHS procedure (Mohs micrographic surgery- a surgical procedure that is completed to treat skin cancer) as the biopsy results indicated squamous cell carcinoma. The MOHS procedure was scheduled for 2/25/2025.2/24/2025- the family member cancelled the MOHS appointment and indicated that s/he no longer wanted the resident going to dermatology appointments.6/26/2025- The facility spoke with the family member, and s/he agreed to allow wound care to assess and treat the wound and s/he felt that the resident would not tolerate going out to the dermatologist for the MOHS procedure.6/28/2025- The facility spoke with family member again, regarding the lesion on right temple, s/he would like wound care to look at it and see if it can be treated in house. S/he does not feel that the resident would tolerate going to dermatology for the MOHS procedure. At this time an order for ointment and Primapore (a non-adherent dressing) to cover area as s/he is picking at it. Record review failed to reveal evidence that the facility monitored or assessed the lesion/wound to the right temple from 2/10/2025 until 6/28/2025 when it was documented that the resident was picking at the lesion/wound. Record review revealed the following physician orders:6/28/2025- an antibiotic ointment to be applied to the open area on the right temple cancer lesion and cover with Primapore.7/15/2025- Imiquimod external cream 5% (a topical medication used to treat certain skin conditions, including basal cell carcinoma apply to right temple every other day.9/4/2025- Metronidazole external gel 0.75 % (an antibiotic medication used to treat various infections caused by bacteria and parasites) apply to the right side of head every other day. Record review of the weekly skin checks from 12/13/2024 through 9/7/2025 failed to reveal evidence that the resident had a right temple wound/lesion. Record review of a nursing progress note dated 9/7/2025 revealed that the resident was sent to the hospital as maggots were found in the right temple wound. The resident was admitted to the hospital with squamous cell carcinoma of right temple with maggots present. Record review of a nursing progress note dated 9/7/2025, authored by Licensed Practical Nurse (LPN), Staff A, indicated that the resident kept picking at the wound. Additionally, the note revealed that Staff A noticed some bloody drainage leaking onto the resident's face and right hand from the wound. When Staff A attempted to clean the wound and the resident's face, she observed some pulsating worms moving inside of the wound, so s/he was transferred to an acute care hospital. Record review of the hospital admission document dated 9/7/2025 revealed that the resident was transferred to the Emergency Department (ED) with a large right-sided wound on the temple which was infested with many maggots. Additionally, the document revealed that the resident was actively picking at the wound while in the ED. Further, it indicated that the wound was irrigated, and many maggots/fly larvae (eggs from the flies) were removed from it.Further hospital documentation revealed that the family member denied MOHS surgery and thought the lesion was being managed conservatively with ointments and topical creams at the nursing home. The note indicates that initially .the patient had a intact skin barrier with no breakage or infestations. But slowly over the course of the last six months the wound marking started to fall out and a full-blown hollow wound was formed . Additional review of this paperwork revealed a 3.5-centimeter lesion with necrotic components at right temporal-parietal region adjacent to the ear and the patient will be referred for resection and skin flap advancement by plastic surgery. During a surveyor interview on 9/9/2025 at 1:39 PM and 9/16/2025 at approximately 12:30 PM with Licensed Practical Nurse, Staff A, she revealed the resident has a cancerous lesion which was found during a dermatology consult a few months ago but got worse over time as the resident kept picking at it. Additionally, Staff A disclosed that the resident had a physician's order to apply Aquaphor ointment to the right temple for two weeks from January to February. However, after the treatment ended, the lesion was left untreated until June, when a topical antibiotic was finally started due to the wound's condition. Further, Staff A revealed on 9/7/2025 she observed maggots in the wound and sent the resident to the hospital. During surveyor interviews on 9/10/2025 at 9:16 AM and on 9/16/2025 at approximately 3:00 PM with the Director of Nursing Services, she acknowledged that the lesion/wound to the resident's right temple had become worse. Additionally, she was unable to provide evidence that the wound was treated or assessed from 2/10/2025 until 6/28/2025. Furthermore, she was unable to provide evidence that the weekly skin checks from 12/13/2024 through 9/7/2025 were accurately completely, as the right temple lesion/wound was not assessed on the weekly skin checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 3/31/2025, revealed in part, that Resident ID #1 became combative with staff and was escorted to his/her room and that the resident was held down in his/her bed to avoid him/her from falling. Additionally, the incident report dated 3/31/2025, revealed that a follow up call was placed from RIDOH to the facility, where the Director of Nursing Services (DNS), revealed that Registered Nurse (RN), Staff A, and Licensed Practical Nurse (LPN), Staff B, restrained Resident ID #1. Review of the facility policy titled, Abuse Prevention Plan reviewed 10/23 states in part, .Abuse is defined as .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care, and is not in the resident's best interest .freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control .manual method means to hold or limit a resident's voluntary movement by using body contact as a method of physical restraint .physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all the following criteria .Restricts the resident's freedom of movement or normal access to his/her body . Record review revealed Resident ID #1 was readmitted to the facility in January of 2025 with diagnoses that include, but are not limited to, dementia and anxiety disorder. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0 out of 15, indicating the resident has severely impaired cognition. Review of the resident's care plan revealed that s/he is at risk for selfcare deficit related to weakness and deconditioning related to advanced dementia with the following interventions in place; if resistive to care, redirect and reapproach at a later time and approach the resident in a calm friendly manner for daily care. Review of the resident's progress notes revealed that on 3/31/2025, at approximately 7:30 PM, RN, Staff C, was on the unit when Resident ID #1 was noted to be agitated and aggressively attempting to enter the room of another resident. Staff A, was assisting him/her out of the other resident's room and escorted Resident ID #1 to the common area. RN, Staff C, left the unit and was called back for Resident ID #1 being out of control and that s/he was combative and was attempting to fight everyone. Staff C, and Staff B, went back to the unit to assist. Resident ID #1 was found sitting in the common area, extremely agitated and combative, throwing his/her walker at staff, kicking, biting, and punching anyone that was in his/her reach. Staff were told to back away from him/her; however, the resident got up and was attempting to head in the direction of other residents. Staff C removed the other residents from the immediate situation and called Emergency Medical Services (EMS) for assistance. At this time LPN, Staff B, and Nursing Assistants (NA), Staff D and E, escorted Resident ID #1 out of the common area and into his/her bed. The NA's left the room and Staff C stayed behind with the resident while Staff B attempted to keep him/her safe until help arrived. Resident ID #1 began kicking and spitting. Staff C, and Staff B, tried to calm the resident down by offering him/her ice cream and music, to which s/he took a mouthful of and spit it across the room. Police and EMS arrived shortly after and without incident, the resident was transferred to the hospital for a work-up. During a surveyor interview on 4/7/2025 at 11:05 AM, with RN, Staff C, she revealed that on 3/31/2025 she received a call from a staff member on Resident ID #1's unit who indicated that the resident was out of control. She further revealed that she and LPN, Staff B, went to the unit to assist. She revealed that upon arrival to the unit she found Resident ID #1 sitting in a chair in the common area with his/her walker in front of him/her and the resident appeared terrified. She revealed that the resident attempted to throw his/her walker at her, so she removed the other residents from the area. She revealed that when she went back to the resident s/he was being assisted from the chair in the common area to his/her room by NA's, Staff D, E, and ,Staff B. She revealed that while the other staff was assisting Resident ID #1 back to his/her room she left to get the resident an ice cream and mats for the floor in case of a fall and went back to his/her room. Upon entering the resident's room she observed LPN, Staff B, push the resident into bed and held him/her down with her hand on the resident's chest. She revealed that she told Staff B to stop and Staff B responded, No [s/he] is not going to act like that. She further revealed that she continued to tell the Staff B to stop. The resident then began to spit at the staff and she revealed that Staff B, held the resident's head to the side with her palm on the side of the resident's head behind his/her ear. She further revealed that she sent both Staff A and B home on 3/31/2025, following the above incident of witnessed abuse. During a surveyor interview on 4/7/2025 at 12:57 PM with NA, Staff D, she revealed that on 3/31/2025 she witnessed RN, Staff A, dragging Resident ID #1 down the hallway by pulling his/her arm and walker. She then observed Staff A to forcefully push the resident into a chair. She revealed that the resident attempted to hit her with his/her walker and stomp on her foot. She revealed another staff member came over to assist by removing the walker from the resident and then the resident bit that staff member's arm. Staff D, revealed that Staff A, then pushed the resident's head backwards to stop him/her from biting. She revealed that at this point RN, Staff C and LPN, Staff B, arrived on the unit. Staff B, brought the resident to his/her room by pulling the resident towards the room and Staff B, said to the resident, you're going to get hurt more than I will. She revealed that she told the staff to stop and attempted to hold the resident's hands to walk him/her down the hall. However, Staff B, continued to pull the resident aggressively and forced him/her into bed. During a surveyor interview on 4/8/2025 at 9:42 AM, with NA, Staff E, she revealed that on 3/31/2025 she was coming out of the shower room on the unit when she saw RN, Staff A, dragging the resident down the hallway by pulling his/her arm and walker. She indicated that the resident looked scared. She then observed Staff A pick up the resident and tossed [him/her] into the chair. She stated that she told the nurse to walk away and take a break. She revealed that after she completed care on another resident, she returned to the common area to check on Resident ID #1 where she observed LPN, Staff B, dragging the resident to his/her room, and Staff E, told LPN, Staff B, to leave the resident alone. She revealed that Staff B, continued to bring the resident to his/her room and that the resident attempted to pull away and almost fell. She stated when they got into the room Staff B, threw [him/her] into the bed and pinned [him/her] into the bed by [his/her] head. She further revealed that she continued to tell Staff B, that the resident was in a safe space and to leave him/her alone. Review of a document titled, Employee Disciplinary Record dated 4/3/2025 for RN, Staff A, revealed that he was terminated due to his failure to follow appropriate procedure while trying to seat a combative resident by physically moving a resident to the chair with unnecessary force which was witnessed by multiple co-workers. Review of a document titled, Employee Disciplinary Record dated 4/3/2025 for LPN, Staff B, revealed that she was terminated due to failing to follow the appropriate procedure by physically restraining a combative patient. Staff B was witnessed holding a resident's head down while the resident was in bed to prevent him/her from getting up. Record review of the facility investigation report dated 4/1 and 4/2/2025 revealed that the facility substantiated the allegation of abuse and both Staff A and B were terminated. During a surveyor interview on 4/8/2025 at 10:32 AM with the DNS, she revealed that she substantiated the allegation of abuse. She revealed that she would have expected the staff to redirect the resident and monitor him/her from a distance once s/he was safe. She revealed that she was unsure why the staff continued to attempt to move the resident or remove his/her walker once the resident was in a chair in a common area and would have expected the staff to walk away. Additionally, she revealed that she would have expected the staff to not restrain the resident in bed, but rather leave him/her alone as s/he was safe. Furthermore, she acknowledged that Resident ID #1 was abused on 3/31/2025. The survey team concluded that a reasonable person would not want to be dragged down the hallway, tossed into a chair or thrown and pinned into his/her bed and therefore this was cited at a the harm level due to the probability of psychosocial harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents, for 1 of 3 residents reviewed for falls resulting in transfer to a hospital, Resident ID #62. Findings are as follows: Record review of a facility policy titled, FALLS REPORTING last reviewed 11/2023, states in part, POLICY: [Facility] is committed to providing an environment that is free from accident hazards over the which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents by identifying, evaluating and analyzing risks/hazards; implementing interventions to reduce risks/hazards; and monitoring for effect and modifying interventions as necessary. Falls with or without injury will be investigated and reported as follows: PROCEDURE .5. The licensed nurse will completely fill out the Event Report in [the electronic health record] and begin a through investigation as to why the fall occurred, including interview of staff involved .6. Obtain written statements from staff caring for resident that shift .9. The licensed nurse will initiate or revise the care plan as necessary and review with nursing staff .10. Falls will be reviewed Monday-Friday at the daily meeting of the IDT [Interdisciplinary Team] for appropriate follow up .12. Falls will be tracked and trended and reported to the Quality Assurance/Performance Improvement [QAPI] Committee at each quarterly meeting . Record review revealed the resident was admitted to the facility in November of 2021 with diagnoses including, but not limited to, repeated falls, morbid obesity, and generalized muscle weakness. Review of an annual Minimum Data Set assessment dated [DATE] revealed the resident requires extensive assistance of 2 or more people while turning side to side from a lying position. Review of a care plan initiated on 8/14/2022 revealed the resident is at risk for falls/injury related in part to muscle weakness and limited range of motion of his/her right shoulder with interventions that include, but are not limited to, full body mechanical lift (hoyer) with 2 assist and .S/P [status post] fall 10-13-23 shower trolley [A stretcher-like, piece of mechanical equipment that provides support to those bathing who have low mobility] removed from unit maintenance to evaluate., the latter intervention initiated on 10/13/2023, the day of the resident's fall. Further review of the care plan failed to reveal evidence that a shower trolley is used for bathing the resident or how many staff members are required to assist the resident while using it to ensure his/her safety. Review of the Facility Assessment last updated in March of 2023, failed to reveal evidence that a shower trolley is a piece of equipment utilized by the facility. Record review revealed the following progress notes: -10/13/2023 at 11:04 AM states in part, 10:40 AM - Resident had a witnessed fall out of the shower trolley in the shower room onto the floor. Upon entering shower room resident observed with pooling blood from below [his/her] facial area .vertical laceration to mid forehead noted and dressed with pressure dressing by paramedics. Resident transferred out .to [hospital] . -10/14/2023 at 3:15 PM states in part, .returned from [hospital] last night with eleven dissolvable stitches to forehead .observed to have bruising around right eye. Edema [swelling] also observed above laceration and to the sides of laceration .Bruising is also observed above laceration and to bilateral sides of laceration. Right eye is observed red and irritated .partially closed due to swelling .observed to have bruising to right knee also .Resident states that [s/he] is very tired from yesterday's traumatic experience . During a surveyor interview with the resident on 1/8/2024 at 1:11 PM and again on 1/9/2024 at approximately 2:00 PM, the resident revealed that s/he had a fall from a shower trolley when attempting to turn from a lying position to his/her left side. S/he further indicated that when pulling on the side rail, it felt loose and broke, and s/he remembers waking up on the shower floor face down in a pool of blood. Additionally, s/he further revealed that there were initially 2 nursing assistants (NA) assisting him/her on the day the accident happened, but the second NA had left prior to the completion of his/her shower. Furthermore, s/he revealed that the side of the shower trolley that s/he fell from was the side that the other NA was positioned on. During a surveyor interview on 1/9/2024 at 12:53 PM with NA, Staff B, she indicated that she was verbally told during orientation that the shower trolley should not be used for a resident that weighs over 250 pounds. She further revealed that there should definitely be two staff members assisting a resident receiving a shower with a shower trolley. Review of the resident's weights revealed the following entries: -10/6/2023: 249.8 pounds -11/7/2023: 258.8 pounds During a surveyor interview on 1/9/2024 at 1:04 PM with the Staff Development Coordinator, she revealed that there is no formal training or competency for staff regarding the use of the shower trolley, but it is discussed during the orientation process. She revealed that for a resident utilizing the shower trolley, 2 staff members should be present to assist the resident with turning and repositioning. During a surveyor interview on 1/9/2024 at 4:01 PM with Registered Nurse, Staff C, he revealed that he was the nurse who assessed the resident after the fall was reported to him. He indicated that the number of staff members to assist with a shower trolley bath is based on the resident's cognition and mobility and may require one to two staff members to assist. He further indicated that the shower trolleys are currently still being used for other residents. During a surveyor interview on 1/10/2024 at 9:49 AM with NA, Staff D, she revealed that she was the NA assisting the resident at the time s/he fell from the trolley. She revealed the trolley was only discussed during her orientation; however, she was never instructed on how many staff members are required to safely assist the resident with bathing when using a shower trolley. She indicated she always asks for assistance because she feels it's unsafe having only one staff member present. She further revealed that she had asked another NA to assist her with bathing the resident, but that NA had left before the resident's shower was completed. Additionally, she revealed that since the incident, she ensures at least 2 staff members are present for the resident's safety. Furthermore, she indicated that the Director of Nursing Services (DNS) had a verbal conversation with her regarding the incident, however no written statement was obtained, nor education/training's provided for the staff that she is aware of. During a surveyor interview on 1/11/2024 at 3:29 PM with the Director of Therapy, she revealed that she was unsure how many staff members are required to assist a resident receiving a bath using a shower trolley but thinks it would require two. During a surveyor interview on 1/10/2024 at 10:41 AM with the DNS, she revealed that there is probably not a formal training course provided by the facility for staff that utilize the shower trolley. She indicated that there should be two staff members to assist with a shower trolley bath for a resident if the resident is either heavy or immobile. Additionally, she revealed that she only verbally spoke with Staff D after the fall indicating the accident did not require a follow up investigation because she felt the fall was a result of a mechanical equipment failure. Furthermore, she confirmed that the shower trolley the resident fell from was an Arjo Shower trolley, which is also the same model of the two remaining shower trolleys in the facility. Review of the shower trolley manual titled, Arjo Shower trolley 084021/084023 dated 4/1991, states in part, Safety regulations Always make sure that: equipment is handled by trained staff .Check every week that: all hoses, pipes, connections, braking devices and wheels are undamaged. Every month: examine shower and panel hoses so that no leaks occur. These hoses should be replaced every five years .the equipment must be used in accordance with these safety regulations and instructions. Anyone using the equipment must also have read and understood the instructions in this booklet. During a surveyor interview on 1/10/2024 at 2:56 PM with the Maintenance Director, he revealed that he is unaware that the user manual indicates to inspect the shower trolley weekly per the safety regulations. He was unable to provide evidence that the user manuals safety regulations were being followed by the facility. During a surveyor interview on 1/12/2024 at 11:08 AM, with the Administrator and DNS conducted during the QAPI task, they were unable to provide evidence that Resident ID #62's fall on 10/13/2023 was addressed at the last QAPI meeting held on 10/26/2023 as per policy. Additionally, the Administrator revealed that the facility was inconsistent with preventative maintenance of the shower trolleys. Furthermore, the Administrator and DNS acknowledged that the resident's fall was not investigated nor was there follow up education provided to the staff following Resident ID #62's fall. During a subsequent surveyor interview on 1/12/2024 at 9:10 AM with the DNS, she was unable to provide evidence that the facility took appropriate measures to identify avoidable accident hazards and thoroughly investigated Resident ID #62's fall on 10/13/2023 as per policy to help ensure the safety of other residents who continue to use the shower trolley. Additionally, she was unable to provide evidence that the facility ensured that each resident received adequate supervision and assistance to prevent accidents. Refer to F 726 and F 908

Based on surveyor observation, staff interview and record review it has been determined that the facility failed to provide assistance devices to prevent accidents relative to the facility failing to utilize the proper mechanical lift (Mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone), the Hoyer lift, for a transfer, for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 3/17/2023 states in part, On March 3, 2023, two CNAs [certified nursing assistants; NA] were assisting a resident .Into bed at approximately 10:30p.m. When they started to stand [him/her], [s/he] complained of pain to [his/her] left leg. The aides sat [him/her] back in .chair and reported the incident to the nurse. The nurse assessed the area and there was no bruising or swelling at that time .placed ice on the thigh for comfort. On 11-7 [s/he] began to complain of increased pain. An order was obtained for Tramadol [a narcotic to treat moderate to severe pain]. At 8 a.m. on 3/4/2023, the NP [nurse practitioner] gave the order to obtain x-rays of .tibia, fibula, knee, and femur. Results were all negative for acute fracture. Tramadol continued for pain as well as biofreeze and ice to .thigh .On 3/13/2023, an order for a second set of x-rays was obtained. The left hip, pelvis .were done. These x-rays showed a healing fracture of the distal femur On 3/15/23, the resident reported an increase in [his/her] pain level and was sent to [an acute care hospital] for evaluation and comprehensive imaging. [S/he] underwent imaging and was diagnosed with a femur fracture. [S/he] has been admitted for further treatment . Record review revealed the resident was admitted to the facility in May of 2013 with a diagnosis that included but was not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), related to the resident having a CVA (cerebral vascular accident; a stroke). Record review of a Brief Interview for Mental Status Assessment was completed in February of 2023 with a score of 15/15, indicating his/her cognition was intact. Record review of a care plan last revised in February of 2023 indicated the resident was at an, increased risk of injury related to h/o [history of] CVA with right sided hemiparesis; poor trunk control and required a mechanical lift for all transfers. Record review of a Physical Therapy PT Evaluation & Plan of Treatment, dated 4/22/2022 indicates the resident is a hoyer lift for all transfers. Record review of a clinical note dated 3/3/2023 revealed the following: .cnas reported to this writer .that they attempted to transfer with EZ lift [a lift used for individuals who have the capacity to lift and support some of their weight when transferring from a seated to a standing position] from WC [wheelchair] to bed .resident reported discomfort and they sat [him/her] back in WC and came to inform this writer .instructed cnas to obtain Hoyer [type of mechanical lift used for individuals who are unable to support their weight when transferring] lift from another unit .resident hovered to bed .assessed extremities .no edema or bruising .no deformities .ice pack applied to left thigh area and elevated on pillow . Record review of clinical notes dated 3/4/2023 indicating the resident c/o [complained of] pain in left knee and posterior thigh, 8/10 pain scale on movement and s/he received scheduled Tylenol 1000mg [milligrams]. Additionally the notes indicate that the NP was notified and new orders for x-rays. Additionally, a one time order Tramadol 25 mg for pain management were given. Record review of a Radiology Results Report dated 3/4/2023 indicated the resident had arthritis in his/her knee, an old fracture of the distal femur and there were no acute fractures or dislocations noted. Additional record review of the clinical notes dated 3/5/2023 through 3/13/2023 revealed the resident continued to experience intermittent pain. Review of a physician's order dated 3/5/2023 revealed a new order for Tramadol 50 mg to be administered every 6 hours as needed for pain. Additional review of the physician orders revealed an order dated 3/13/2023 for x-rays of the left lower leg. Record review of a Radiology Results Report dated 3/13/2023 revealed an old fracture of the distal femur with impaction and the impression was a healing fracture of the distal posterior femur. Record review of a clinical note dated 3/15/2023 indicated the NP was in to see the resident who was continuing to experience increased pain in his/her left leg. Additionally the note indicated the NP reviewed the resident's x-ray results and ordered the resident to be transferred to an acute care hospital to determine if the left femur fracture was old or new. Record review of an ED Hosp-admission Note provided by the emergency department provider dated 3/15/2023 indicated the resident had x-rays and a CT scan (X-Ray technology to produce images of the inside of the body) of his/her left knee that indicated s/he had a transversely oriented and impacted trabecular fracture [horizontal break] involving the supracondylar distal femur [thigh bone that has a break starting at the knee]. During a surveyor interview on 3/20/2023 at approximately 1:05 PM with NA, Staff A, she revealed that Resident ID #1 was a Hoyer lift and that on the day of the incident, the battery for the Hoyer lift was dead and Staff B, who was working with her on the transfer, stated let's use the, EZ Stand. She further revealed that when the resident began to bear some of his/her own weight s/he began complaining of pain. During a surveyor interview on 3/20/2023 at approximately 1:15 PM with NA, Staff B, she stated, I thought we could have lifted [him/her] with the EZ stand, [s/he] slightly began to bear weight on both legs and complained of pain during the transfer. During a surveyor interview on 3/20/2023 at approximately 1:25 PM with Registered Nurse, Staff C, she revealed that she was told by Staff A and B that they used the EZ stand to transfer Resident ID #1 and s/he complained of pain during the transfer. Additionally, she revealed that after the incident, she had instructed Staff A and B to use the Hoyer lift from another nursing unit to transfer the resident to bed. During a surveyor interview on 3/20/2023 at approximately at 2:15 pm with the Director of Nurses, she acknowledged Resident ID #1 should not have been transferred with the EZ stand lift. Additionally, she revealed that the resident has not been able to stand in seven years.